Rains County, Texas

                      Application for Certified Copy of Death Certificate
 
Note: Prices are from 2010 so check with County Clerk for Price changes.


_____ certified copies x $23.00 = $_________
_____additional copies x $3.00 = $________

 

1.  Name on record _________________________________________________________________
                               (First)                                    (Middle)                                              (Last)
2.  Date of event ___________________________________________________________________
                               (Month)                         (Day)                      (Year)
3.  Place of event ___________________________________________________________________
                               (City) or (County)
4.  Father's name ___________________________________________________________________
                               (First)                                    (Middle)                                              (Last)
5.  Mother's name __________________________________________________________________
                               (First)                                    (Middle)                                              (Last)
6.  Applicant's name ________________________________________________________________
                                   (First)                                    (Middle)                                              (Last)

7.  Applicant's mailing address _________________________________________________________
                                               _________________________________________________________
     Applicant's telephone number (Mon day- Friday, 8:00 - 5:00) ________  ______________________
8.  Applicant's relationship to person named in #1 ___________________________________________
9.  Applicant's purpose for obtaine named record ___________________________________________
10.  Additional identifying information for DEATH CERTIFICATE
       Social Security No. for Death Certificate _____________________________________________
       Date of Birth __________________________________________________________________
       Place of Birth __________________________________________________________________
 

________________________________________________________  _______________________
Signature of Applicant                                                                                  Date

Identification _____________________________________________________________________
**Attach photocopy of driver's license, I.D. Card., etc.
 

Death records are confidential for 25 years.  Therefore, issuance is restricted.  Other records may be obtained when sufficient information for identification is provided.

Please attached a photocopy of I.D. to application

WARNING: The penalty for knowingly making a false statement in this form can be 2-10 years in prison and a fine up to $10,000 (Health & Safety Code, Chapter 678. Sec 195.003)

Mail form to:
Linda Wallace
Rains County Clerk
P.O. Box 1150
Emory, Tx 75440
 

 Back

 Home