DARKE COUNTY HEALTH DEPARTMENT
300 GARST AVENUE
GREENVILLE, OHIO 45331
(937) 548-4196
REQUEST FOR CERTIFIED DEATH CERTIFICATE
Name of Deceased______________________________________________________________
Date of Death_________________________________________________________________
Place of Death_________________________________________________________________
County City or Village
Father’s Name_________________________________________________________________
Funeral Director_______________________________________________________________
Signature of Person Making Application______________________________________________
Date__________Address: _______________________________________________________
Phone Number: ________________________________________________________________
Number Of Copies Requested:__________
**$23.00 per certified copy
**Please include money order payable to: Darke County Health Department
Sorry, we cannot accept check or credit card payments. We also cannot fax
birth certificates.
If requesting
a certificate in person, we accept only cash, money orders, or checks with a
valid driver's license identification.
**Please include a self addressed stamped envelope for the death certificate to be mailed back to you.
Page Last Updated: 3/11/2010