APPLICATION FOR CERTIFIED DEATH CERTIFICATE
(Please Print)
Full name at Death ______________________________________________________
Date of Death ____________________ Town of Death __________________________
Relationship to the Deceased ________________________________________________
INFORMATION OF PERSON MAKING THIS APPLICATION
Name: ________________________________________________________________
Address: ________________________________________________________________
City: ______________________________ State ______________ Zip _____________
Phone #________________________________
Applicant’s Signature _________________________ Date: _______________________
Fee: $20.00 per copy Number of Copies Requested ____________
** Note: Per CT law (C.G.S. §7-51A), for deaths occurring on or after July 1, 1997, only the surviving
spouse, next of kin, or funeral director who is acting on behalf of an eligible family member, may obtain a
copy of the death certificate with the decedent’s Social Security number listed on the death certificate. All
other requesters will receive a certified copy without the decedent’s Social Security number.
If eligible, do you want the decedent’s Social Security number on the copy of the certificate?
No: _____ Yes: _______ (if Yes, You must provide proof of eligibility)
TO EXPEDITE YOUR REQUEST PLEASE INCLUDE:
Certified check or money order made payable to: Meriden City Clerk
Please include a stamped self-addressed envelope
Mail To: Denise L. Grandy - City Clerk
142 East Main St., Room 124
Meriden, CT 06450
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