TOWN OF LANCASTER, NEW HAMPSHIRE

DEATH CERTIFICATE APPLICATION

INSTRUCTIONS:

1.    Print the application to complete.

2.    Check to make sure all information is complete, legible, and sign the application.

3.    Enclose a check or money order made payable to Town of Lancaster.

4.    A copy of a photo ID is required for the person requesting the certificate.

5.    Include a self addressed stamped envelope for the return of the certificate(s).

6.    Mail the request to: Lancaster Town Clerk, 25 Main Street, Lancaster, NH 03584.

PLEASE TYPE OF PRINT

Date:_____________________

Type of Certificate Requested: (Please check one).

______# of certified copies requested      _____ Long Form (issued with cause of death)    _____ Short Form

The first copy is $12.00 and each additional copy (requested at the same time) is $8.00.

Name of Deceased________________________________________________________________

                                               First                                              Middle                                      Last

Date of Death:__________________  Place of Death______________________________________

                                 month         day             year

Father's Name___________________________________________________________

                                             First                                              Middle                                       Last

Purpose for which certificate is requested:________________________________________

(Example: genealogy, insurance, school, ID, Travel)

Your Name___________________________ Telephone Number_____________________

Your Address_____________________________________________________________

Your Signature_____________________________________

Your relationship to the registrant (person for which copy is requested)_____________________

***The above information is required.  If the application is not complete, it will be rejected.

A fee of $12.00 is required by law for the search of the file for any one record. 

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)