FORM TO BE USED WHEN REQUESTING A
CERTIFIED COPY OF A DEATH RECORD LISTING CAUSE OF DEATH
DATE:_____________________________
I, _______________________________(applicant), ________________________________(relationship) to decedent, hereby authorize the issuance of a certification of the death record of _____________________________, disclosing the cause of death section.
I hereby certify that the above answers and information are true. I understand that if I have made any false or provide misleading information, I am subject to punishment and guilty of a disorderly persons offense. (New Jersey Administrative Code 2C:28-3, "Unsworn Falsification To Authorities")
Print Your Name:___________________________Your Signature:_______________________
Health Dept. Witness ________________________Date: ________________________________
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