APPLICATION FOR A CERTIFIED COPY OF A DEATH CERTIFICATE
Office of the City Clerk/ One City Hall Plaza/ Manchester, NH 03101/ 603-624-6455
Name of Deceased:
(First Name) (Middle Name) (Last Name)
Date of Death: _______________ Pl
ace of Death (City/Town):
Issue With Cause of Death:
Issue Without Cause of Death:
Purpose for which certificate is requested:
Your Signature:
Your relationship to deceased:
Please Print All Information
NH State Law for the search of the file requires a fee of fifteen dollars for any one record. The State
also requires a valid picture identification of the individual applying for the death certificate before a
record will be released. If we find that record and you meet New Hampshire’s access requirements,
you will be issued one certified copy of that certificate. THE FEE IS NON-REFUNDABLE IN THE
EVENT THE RECORD IS NOT LOCATED.
Number of Copies:
($15 first copy, $10 each additional)
The certificate(s) will be mailed to the following address: (please print)
Name of applicant:
(First) (Middle) (Last)
Address of applicant:
(Street) (City/Town) (State) (Zip Code)
Applicant Phone #: Email Address (optional)
NOTICE
Any person shall be guilty of a CLASS B felony if he/she willfully and knowingly makes any false
statement in an application for a certified copy of a vital record. (RSA 126:24)
Please mail completed application to address above and include a stamped envelope for return service.
OFFICIAL USE ONLY:
Number
Requested
Issued
