Full name of deceased_______________________________________Race__________

Date of  Death_________________Place of death_____________________________,Oklahoma
          (MO)           (Day)            (Year)                                          (County)                              (City)
Check box if death was stillbirth or fetal death [_]

Funeral director in charge________________________________Address___________________

Purpose for which this copy is needed______________________________________________

Signature of person making application________________________________________ Date of App. ____

                                                                                                                                          Number of copies wanted @ $10.00________
PLEASE PRINT CORRECT MAILING ADDRESS BELOW:                                          Fee enclosed $__________
                                                                                                                                         ENVELOPE WITH THIS APPLICATION
____________________________________________________                    SELF-ADDRESSED
 (Name)                                                                                                                            ENVELOPE WITH THIS APPLICATION

_________________________________________
 (Street Address)

___________________________________________________________
    (City)                                           (State)                                               (Zip)

Request for a search of the records for a death certificate of any person who died in the State of Oklahoma should be submitted on this blank along with the required fee of $10.00. If the death certificate is on file a certified copy will be mailed. The information requested above should be filled in careful and accurately. It is the minimum needed to make a thorough search for a death record. Send ten dollars ($10.00) in cash, money order or check for each copy desired. Cash is sent at sender's risk. Make checks or money orders payable to the State Department of Health. A copy required to be submitted to the Veterans Administration or U.S. Commissioner of Pensions, in connection with a claim for military-service-connected benefits may be obtained without fee provided a signed statement is attached which sets forth these facts and requests that the copy be issued without fee. Members of the armed forces and veterans must pay regular fees for copies to be used for all other purposes.