Name of Decedent:_________________________________________

Date of Death:_____________________________________________

Location of Death:__________________________________________
(home, hospital, etc) 

Reason for Request:  Legal      or      Genealogy


If request is for genealogy, we will include additional information. 

Person requesting certificate: _________________________________

Address:          Street,
P.O. Box or R. R. # ______________________________

City: ________________________ State:_________

Tel.#________________________ Zip:___________

Date:__________ Signature: X_________________________________

GIBSON COUNTY DEPARTMENT OF HEALTH
800 S. Prince
Princeton, IN 47670
Phone: (812) 385-3831
Fee $10

WARNING: False application, altering, mutilating or counterfeiting
Indiana death certificates is a criminal offense under I.D. 16-37-112.