Application for Search of Death Record Files

City of Belvidere - Illinois

City Hall: 401 Whitney Blvd., Belvidere, IL 61008 - (815)544-2612
Application for Search of Death Record Files
Full Name of Deceased:*
Place of Death:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Death:*
Sex of Deceased:
Race of Deceased:
Usual Occupation of Deceased:
Date last known to be alive:

MonthDayYear
Date
Last known address of Deceased:
Marital Status of Deceased:
Date of Birth of Deceased:
Birthplace of Deceased:
Name of Husband or Wife of Deceased:
Full Name of Father of Deceased:
Full Name of Mother of Deceased:
Date of Request:

MonthDayYear
Date
Application made by (Name):*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Applicant's Relationship to Deceased:*
Intended Use of Record:*
Mail copy to:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Number of Copies Desired:*
Any request for a certified copy of a vital record requires a copy of the applicant's current/valid photo ID per the Illinois Division of Vital Records. Please upload current/valid photo ID.*

Cancelof
Signature:*

Clear
Cost of Certificates: $14.00 for the first copy, and $6.00 for each additional copy. Certified copies will be mailed after request and payment have been processed.
Should be Empty:

City of Belvidere - Illinois