Free 49606.FH11 - Indiana

APPLICATION FOR SEARCH AND CERTIFIED COPY OF DEATH RECORD
State Form 49606 (R3 / 3-08) Approved by State Board of Accounts, 2008

INDIANA STATE DEPARTMENT OF HEALTH

DEATH RECORDS IN THE STATE VITAL RECORDS OFFICE BEGIN WITH 1900. Prior to 1900, records of death are filed ONLY with the local health department in the county where the death actually occurred. For deaths occurring from 1900 to 1917, the city and/ or county of death is required in order to locate the record. FEES ARE ESTABLISHED BY LAW (IC 16-37-1-11). Each search for a record costs $8.00. The fee is non-refundable. Included in one search is a 5-year period: the reported year of death and, if the record is not found in that year, the 2 years before and after. For records prior to 1917, the search covers a 5-year period and only one county. A certified copy of the record, if found, is included in the search fee. Additional copies of the same record purchased at the same time are $4.00 each.

IDENTIFICATION IS REQUIRED according to IC 16-37-1-7, (e.g., photocopy of drivers license, work identification card, etc.) . DO NOT SEND ORIGINALS IN THE MAIL. Requests for death certificates sent without proper identification will be returned to the requester without processing. Please complete all items below as required pursuant to IC 16-37-1-10 (a):
Name of deceased* Stillborn?

Yes

No

*(If decedent was a married, divorced, or widowed woman, ISDH must have her legal name at the time of death. Please do not give the maiden name of a woman who changed her name by marriage during her lifetime.)
Date of death (month, day, year) City of death Total certificates County of death Total fee(s)

With cause of death: __________ Without cause of death: ___________
Delivery preference

Regular Mail
Date of birth of deceased (if known) Name of father

Express Courier (requires an additional fee)

Pickup

Customer Waiting

Maiden name of mother

Your relationship to the individual named on the requested certificate Purpose for which the record is to be used Signature of applicant Printed name of applicant Mailing address (number and street, city, state, and ZIP code)

Daytime telephone number (including area code)

Todays date (month, day, year)

Send this application, check or money order payable to the Indiana State Department of Health, and a copy of your identification to: Vital Records, Indiana State Department of Health, PO Box 7125, Indianapolis, IN 46206-7125.

FOR OFFICE USE ONLY
Date received (month, day, year) Certificate number Receipt number Application number Volume number Initials of verifier

IC 16-37-1-10 ALLOWS THE STATE REGISTRAR TO ISSUE A CERTIFICATION OF BIRTH, DEATH, OR STILLBIRTH REGISTRATION UPON REQUEST BY ANY PERSON ONLY IF THE STATE REGISTRAR IS SATISFIED THAT THE APPLICANT HAS A DIRECT INTEREST IN THE MATTER; OR THAT THE CERTIFICATE IS NECESSARY FOR THE DETERMINATION OF PERSONAL OR PROPERTY RIGHTS OR FOR COMPLIANCE WITH STATE OR FEDERAL LAW.
The following individuals are considered to have a direct interest and are eligible to receive a copy of a death certificate: 1. 2. 3. 4. 5. 6. 7. 8. 9. Parents Spouse / Life Partner Adult Children Grandparents Siblings Aunts / Uncles Direct Descendents (Grandchildren, Great-grandchildren, etc.) Nieces / Nephews Other family members*

*Other family members may include cousins. Distant relatives will only be issued copies of the death certificate with the approval of the State Registrar and/or designee unless the record is 75 years old.