Certified Death Certificate Request Form

Name of the funeral home:* Slabinski Funeral Home (since 1917)Sucharski Funeral Home (since 1957)Fox Funeral Home (since 1995)Baj Funeral Home (since 1988)

Name of Decedent:*
Date of Death:*
Place of Death:*
Date of Birth:*
Social Security Number:*
Age at time of death:*
Mother's Name:*
Father's Name:*
Was the deceased a Veteran:* YESNO

YOUR INFORMATION

Name requesting the information:*
Relationship to the Decedent:*
ADDRESS OF REQUESTOR
Street:*
City:*
State:*
ZIP:*
Phone Number:*
Email Address:*
Number of certified death certificates needed:*

*We provide a service at the funeral home to obtain certified copies for the convenience of families to handle personal matters. The cost of the certificates vary depending on the state that the death occurred. If you wish for us to obtain certified copies, please complete the form and provide your information and we will reach out to you regarding costs. All costs must be paid in advance prior to us obtaining the certified copies. Thank you very much.