GENESEE COUNTY CLERK APPLICATION FOR DEATH RECORD (Please Print) APPLICANT INFORMATION (Person Requesting Record) Applicant's Name: _____________________________________________________________________ Address: ____________________________________________________________________________ City/State/Zip_________________________________________________________________________ Daytime phone number to contact you if there is a problem: ( ) ____________________________ APPLICANT'S SIGNATURE: ________________________________________________________ Must be Signed in Order to Process REQUESTED DEATH INFORMATION (Death Must Have Occurred in Genesee County) Name at Death: ______________________________________________________________________ First Middle Last Date of Death: __________________________ Month Day Year Place of Death: _____________________________ City County The fee is $25.00 for the first copy, and $10.00 for EACH ADDITIONAL COPY of the same record when ordered at the same time as the first copy. Number of Copies Requested: ____________ Mail this application with a MONEY ORDER payable to: Genesee County Clerk Vital Records 900 S. Saginaw St. Flint, MI 48502 For additional information call (810) 257-3225 American LegalNet, Inc. www.FormsWorkFlow.com