WAYNE MOTLEY, CITY CLERK
847 599-25
DATE/FECHA___________________
YOUR NAME/SU
NOMBRE:________________________________________
PRESENT ADDRESS/
DOMICILIO:______________________________________________________
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The fee for any death record is $8 for a certified
copy. The fee is $4 for each additional
copy of the same record issued within 30 days.
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REQUEST FOR DEATH RECORDS
QUANTITY NAME OF DECEASED DATE OF DEATH
_________
__________________ _______________
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El cobro por
una petición de
un certificado de defunción
es de $8.00 por la primer copia certificada y $4.00 por cado copia
adicional si es expedida en 30 dias.
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PETICION DEL CERTIFICADO DE DEFUNCION
CUANTAS
COPIAS NOMBRE DEL_FALLECIDO_ FECHA DE FALLECIMIENTO
_______
_______________________
________________________
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___________________________________________
REQUESTER’S SIGNATURE
FIRMA DE LA PERSONA QUE ESTA REQUIRIENDO EL CERTIFICADO
FEE AMOUNT $_________ CLERK___________ RECEIPT# ___________