APPLICATION FOR CERTIFICATE OF DEATH
KAREN S. COLE, CABELL COUNTY CLERK
VITAL STATISTICS DEPARTMENT
750 5th Ave-Suite 108
Huntington, WV  25701
NOTE: A $5.00 search fee and self addressed
stamped envelope must accompany this application.
This fee is not refundable. Each additional copy is
$5.00 per copy. Check or money order payable to the CABELL COUNTY CLERK.

QUANTITY

                      

For Office Use Only:
Cash
Check
M/O
No. Copies
AMOUNT
DEATH Decedent's Name-
 		 FIRST
 		 MIDDLE
 		 LAST
 
Date of Death
 		 MONTH
 		 DAY
 		 YEAR
 
PLACE
 		 CITY
 		 COUNTY
 		 STATE
 
WHAT IS YOUR RELATIONSHIP TO PERSON
NAMED ON CERTIFICATE?

                                                                   

SIGNATURE OF APPLICANT

                                                   

PLEASE PRINT-DO NOT WRITE

*NOTE: PLEASE PRINT THIS FORM, COMPLETE AND SIGN AND MAIL  TO OUR OFFICE.