APPLICATION FOR A DEATH CERTIFICATE PLEASE READ THESE NOTES before completing this form.

Death Certificate Stourbridge Register Office : WOD/3/249

1 TO BE COMPLETED BY THE APPLICANT Name of applicant Mr Mrs Miss/Ms (STATE NAME IN FULL) Full postal address   Post Code: Telephone no: e-mail address:

2 Please state your relationship to the person to whom the certificate relates:

3 DETAILS OF DEATH CERTIFICATE REQUIRED
SURNAME OF DECEASED CRUMP	DATE OF DEATH 1963
	PLACE OF DEATH (Full address or name of hospital) Wordsley (WOD)
FORENAME(S) Arthur
OCCUPATION	DATE OF BIRTH or AGE AT DEATH-
HOME ADDRESS	If a married woman, please give name and surname of husband

4 REQUIREMENTS	Send this Application to:
DEATH CERTIFICATE £11.00	Superintendent Registrar, Dudley District Register Office, Priory Hall, Priory Park, Dudley, West Midlands, DY1 4EU, UK
I requireNUMBER death certificate(s)

5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)

UK: applications should enclose an SAE. Postal order or cheque made payable to : Superintendent Registrar for £ 11.00 Overseas: applications should enclose a self addressed envelope and two IRCs, with payment by Bankers Sterling Draft payable to : Superintendent Registrar

The Fee for a certificate issued against this form 'as printed' will not be refunded. You are strongly recommended to add any qualifying information you may have in order to help the registrar issue the correct certificate.