Death Certificate, Request for

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Death Certificate, Request for

Date:

To: Whom It May Concern:

Please forward to my attention a certified death certificate for:

Exact Name:

Date of Death:

Town or City of Birth:

Sex:

I am the Executor or Trustee acting on behalf of the Estate of the Deceased. A copy of my authorization is enclosed.

Enclosed is my credit card information for your use to pay for my request:

Credit Card Number:

Expiration Date:

Exact Name on Card:

If you require a check instead, please send me the amount due in the enclosed stamped self-addressed envelope and I will send it to you by return mail.

Thank you for your assistance in this matter,

Best regards,

_____________

Executor or Trustee

Enc. Authority to Act