ࡱ> molo 9bjbj xzfzfm < < 8\)46%@]Dx|@a$c$c$c$c$c$c$$v',*$i "  $$""" La$" a$""#)# Ed d#M$%06%!#* *)#*)#$4"V"n444$$ 4446%    *444444444< G:  Application for a Certified Copy of a Death Record Please complete ALL items 1-5 below. If you type your information, use the tab key on your keyboard to move to each gray-shaded field. 1. Please fill in the information below for the person whose death record you are requesting. Full name:  FORMTEXT      Date of death:  FORMTEXT      Place of death (city/town/hospital name):  FORMTEXT      Name of spouse/civil union partner/domestic registered partner (if applicable):  FORMTEXT      Mother s/parent s full name at birth:  FORMTEXT      Father s/parent s full name at birth:  FORMTEXT       2. I am applying for the death record of (complete one of the following):  FORMCHECKBOX  my parent  FORMCHECKBOX  my spouse/civil union partner/registered domestic partner  FORMCHECKBOX  my child  FORMCHECKBOX  my grandparent  FORMCHECKBOX  other relative (specify):  FORMTEXT        FORMCHECKBOX  my client. I am an attorney representing:  FORMTEXT      . The name of the law firm is:  FORMTEXT        FORMCHECKBOX  my client. The name of the insurance company is:  FORMTEXT        FORMCHECKBOX  another person (specify):  FORMTEXT       3. Why do you need this record? (We ask this question so that we can supply you with a certified copy that will be suitable for your needs.)  FORMCHECKBOX  probate  FORMCHECKBOX  Social Security  FORMCHECKBOX  Vets benefits  FORMCHECKBOX  property title  FORMCHECKBOX  foreign government (specify country of use):  FORMTEXT        FORMCHECKBOX  other use (specify):  FORMTEXT       4. Walk-In Copies cost $22. Mail-In Copies cost $25. Additional copies of this record purchased the same day cost $18 each. How many copies do you want?  FORMTEXT       (Make(-456   ' ( 2 3 4       . 0 D F H J L N P R T V ׿o"jhh15U^J$jhh15PJQJU^J"jhh15U^Jhh15^Jjhh15U^J h1h1 h15h hxhdw5hdwhdw5h-h1hdw h@>h9ljh/UmHnHu*56   V Gkdt$$Ifl 0*") t644 la p yt $Ifgd1gddwgdlgd9l p t v         $ 6 J \ ` b v x ߷߷߷"jhh15U^J"jhh15U^J"j,hh15U^Jhh15^Jh1 h1h1$jhh15PJQJU^Jjhh15U^J"jLhh15U^J2  NGkd$$Ifl 0*") t644 la p yt $Ifgd1_kd$$Ifl0 R0*8  t644 la pyt  " * *2fa\\PPP dh^gd6gddwgd9lGkd0$$Ifl 0*") t644 la p yt $Ifgd1Gkdh$$Ifl 0*") t644 la p yt x z | ~ " ( * , H J L N | ~ 468:<XZ\xzɻɰץװג|׎qjh(cUjlh(cU hdwh1h1jh(cUjh(cUjh(cUjh1h1U h65\ h15\hdwhdw5\h9l h1h1$jhh15PJQJU^Jjhh15U^J,z|~ "$&(*,HJLN   ǽǘǽ{ǘǽ"jh59h15U^Jj<h(cU$jh59h15PJQJU^J"jh59h15U^Jh59h15^Jjh59h15U^JjTh(cUh6 h1h1jh1h1Ujh(cU* "$&(*,.024PRTVp>@TVXZ\^źůţߙź|ߙj"j h59h15U^Jj h(cU"j h59h15U^Jh59h15^Jh6jh(cUjh(cUjh1h1U h1h1$jh59h15PJQJU^Jjh59h15U^J"j$h59h15U^J)2fABr.t.\///0D1F11:2<2 $Ifgddwgd9l`gdx^gd1gddw dh^gd6^`bdf'@ABCQRST^_`nopqzƼצך׏ױ׀ױuױj h(cUjT h(cUhJBj h(cUh#|jh(cUjl h(cUjh1h1Uhdwh65\ hdw5\hdwhdw5\ h1h1jh59h15U^J$jh59h15PJQJU^J*  .024`bvxzҿځrhVr"j h59h15U^Jh59h15^Jjh59h15U^Jj& h(cUh1$jh59hW5PJQJU^J"j h59hW5U^Jh59hW5^Jjh59hW5U^JhxlhWh#| h1h1jh1h1Ujh(cUj< h(cUz|~*@^nƿДxeeeeeahx$jh59hdw5PJQJU^J"jh59hdw5U^Jh59hdw5^Jjh59hdw5U^Jhc@h~5>*\hdwh~5\ h~5\ hc@5\hdwhdw5\ hdwhdw h1h1jh59h15U^J$jh59h15PJQJU^J& check/money order payable to: General Treasurer of RI) 5. I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section 23-3-28 of the General Laws of RI (printed below). Please sign ______________________________________________________________ ______________________ signature of person completing this form date signed Type or print your name:  FORMTEXT      Type or print your phone number: (  FORMTEXT     )  FORMTEXT       Type or print your address:  FORMTEXT       (include street or mailing address, city/town, state, and zip code.) ATTACH PHOTOCOPY OF VALID GOVERNMENT ISSUED PICTURE ID From Section 23-3-28 of the General Laws of Rhode Island:  23-3-28 Penalties.  (a) Any person who willfully and knowingly makes any false statement in a report, record, or certificate required to be filed under this chapter, or in an application for an amendment of those, or who willfully and knowingly supplies false information intending that this false information be used in the preparation of any report, record, or certificate, or amendment [& ] shall be punished (if convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not more than one (1) year or both.     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