Death Certificate

[OFFICIAL NAME]

Date: September 23, 2015

This is to certify that the records in my office show that

Mr. / Miss/ Mrs. --------------------------------------------------------------------------------------

(Name of dead person)

Died at [TIME] on [DATE] Day of [MONTH] and [YEAR].

Gender: [MALE/FEMALE]

Age: [ENTER AGE HERE]

Cause of Death:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Occupation: _____________________________ Marital Status: [Marital Status]

I have hereunto affixed my signature alongside a witness on [DATE], Day of [MONTH],

[YEAR]

(Date of signature)

We are issuing this certificate on the specific request of [Name] without accepting any
liability on behalf of this certificate or part of this on our organization/company.

[Authority]

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