DeathCertificate.pdf

FOR OFFICE USE ONLY

TODAY’S DATE________________

CASH AMOUNT________________________

CHECK # ________________ AMOUNT________________

CHARGE AUTH #_______________AMOUNT___________

For Office Use Only

Pick Up/Mailed ________

PUBLIC HEALTH AND

SOCIAL SERVICES DEPARTMENT

Vital Records

412 Lilly Road NE

Olympia, WA 98506-5132

(360) 867-2618 Fax: (360) 867-2600

APPLICATION FOR DEATH CERTIFICATE

PLEASE FILL OUT THE INFORMATION LISTED BELOW :

NAME OF THE DECEASED ___________________________________________________________

DATE OF DEATH ____________________________________________ (month, day, year)

CITY OR COUNTY OF DEATH ________________________________________________________

(THURSTON COUNTY DEATHS ONLY)

ENCLOSE $20.00 FOR EACH CERTIFICATE ORDERED OR BRING THIS APPLICATION TO THE

THURSTON COUNTY PUBLIC HEALTH AND SOCIAL SERVICES DEPT.

a. How many certificates do you want _________ X $20.00 = $_______________________

PLEASE FILL OUT THIS SECTION FOR PICK-UP OR MAILING:

a. Name

b. Address

c. City_________________________State_____________________Zip

d. Phone number

Certificate to be: PICKED UP OR MAILED

PAYMENT METHOD: Check One (X)

Amount Paid $________ □ Check # ________ (Payable To: TCHD) □ Visa □ MasterCard

Card Number ____________/____________/____________/_____________

Expiration Date ___ ___ / ___ ___

Cardholder name & address (if different than above) ____________________________________________

Applications can be mailed or delivered to:

Thurston County Public Health and Social Services – ATTN: Vital Records

412 Lilly Road NE; Olympia, WA 98506-5132

Faxed to: (360) 867-2600

To print a copy of this application, visit us our website at: http://www.co.thurston.wa.us/health/admin/vitals/index.html

O:\PerHealth_Reception\Vital Records Form/|DeathCertificateForm.docx/pdf

Revised 07/11/11-esn