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

Death Certificate Cheshire East : BU/03/077

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 HARDING	DATE OF DEATH 1846
	PLACE OF DEATH (Full address or name of hospital) Bunbury
FORENAME(S) Elizabeth
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, Cheshire Central Register Office, Municipal Buildings, Earle Street, Crewe,CW1 2BJ, UK
I requireNUMBER death certificate(s)

5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
Applications should include a Postal order or cheque made payable to : Cheshire East Borough Council for £ 11.00 which includes second class postage. If you would like the certificate to be sent by first class post, please add £1.00 for UK deliveries, £1.50 for Europe and £2.00 for the rest of the world.
If paying by Credit Card: Please debit my account by the amount: £		Type of card (e.g. Visa, Mastercard or Switch):
Name on Card:		Card Expiry Date (DD/MON/YYYY):
Enter both Card Number & Security Code. Card Number:                                       Security Code:
Signature:   Date:   Card Issue No. : (Switch only) Card Start Date (DD/MON/YYYY): (Switch only)
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.