You must use this form, along with the required identification materials (see below) to receive death certificates by mail from the Winnebago County Clerk. Print out the request form and send it along with $15.00 (1st copy) + (if needed) $4.00 (2nd copy)- (check or money order) and proper identification - to the address on the form.
Cut along dotted lines
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JOHN SCHOU, County Clerk |
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Winnebago County Administration Bldg. |
404 Elm Street, Rm. 103 |
Rockford, IL 61101 |
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DEATH CERTIFICATE REQUEST |
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No. of Copies ______ **Please send copy of actual record** |
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CHECK ONE: _____CERTIFICATION OF DEATH |
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OR |
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_____DEATH RECORD |
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Name of Deceased____________________________________________ |
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Date of Death____________Place of Death_____________________ |
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I, the undersigned, do hereby certify that I am entitled to |
receive the above Death Certificate for genealogy purposes |
under Chap. 111 1/2 Para 73-24 of the Illinois Compiled |
Statutes; or I am the legal representative, parent, spouse, |
or child of the deceased, and legally entitled according |
to the Illinois Compiled Statutes. |
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______________________ ________________________________ |
Print Your Name Your Signature |
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______________________ ________________________________ |
Address Relationship to Person on Document |
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______________________ ________________________________ |
City Phone |
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**THIS AREA FOR MAIL-IN ONLY** |
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Mail to: Name ___________________________________________ |
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Address___________________________________________________ |
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City_________________________State_________Zip____________ |
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Date Mailed:_______________Deputy:________________________ |
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Acceptable
Identification to Receive Records
- For Mail In Requests, a Photocopy of One of the following must be included.
- All documents must be current and valid.
- The Winnebago County Clerk's Office Reserves the right to request additional identification to receive records.
* One of the following......
- Illinois Driver's License
- Illinois State Identification Card
- Out-of-State Drivers License or State ID Card
- U.S. Government Driver's License
- Naturalization Certificate
- U.S. Military Identification Card
- U.S. Immigration Card
- Selective Service Card
- Illinois Public Aid ID Card with Medical Card
* or two of the following.......
- Social Security Card or Print-out
- Voter Registration Card
- W-2 Form
- Bank Statement (within 90 days)
- Utility bill (within 60 days)
- Vehicle Registration Card
- Active Insurance Policy (at least one year old)
- Checkbook or Savings book (showing name and address)
- Employee Identification Card
- Traffic Ticket
- Resident Alien Card
- School Identification Card
[Winnebago County] [County Clerk] [Birth] [Marriage] [Taxes] [USGenWeb] [ILGenWeb]
Katy
Hestand
County Coordinator
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This page created by Cecelia Yeruski for the ILGenWeb Project.
Last updated: Monday, 18-Apr-2005 10:03:08 MDT