Death Certificate Request Form

Possible reasons/needs for ordering a death certificate include:

Life Insurance Proceeds
Sell or transfer stocks and bonds
Sell or transfer Real Property
Veterans Benefits
Social Security Benefits
Employee benefits and pensions
Bank and Loan transactions
IRS for Income Tax records

Thanks for taking the time to fill out our Death Certificate Request Form. The information provided on this form will help Lane Funeral Homes complete the death certificate.

Please complete (as much as possible) the information on the form and select 'Submit Request' at the end to send the request to us.

If you have any questions whatsoever, please contact Lane Funeral Homes at: (330) 744-2289

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Deceased Vital Statistics for Death Certificate:

* Deceased First Name:

* Deceased Last Name:

Street Address:

City/Town:

County:

State:

Zip Code:

Date of Birth:

Place of Birth:

City:

State:

Country:

Date of Death:

Place of Death - Location:

If other location, please indicate:

Place of Death - Name:

Place of Death - Street:

Place of Death - City:

Place of Death - State

Place of Death - County:

Full Name of Surviving Spouse:

Death Certificate Quantity Requested:

First copy: $ 10.00
Each additional copy: $ 10.00

Informant/Person In Charge Information:
* First Name:
* Last Name:
Relationship To Deceased:
* Email Address:
Telephone Number:

Other Information & Instructions
Please list any other information or instructions you would like us to have:

Death Certificate Request Form

Possible reasons/needs for ordering a death certificate include:

Deceased Vital Statistics for Death Certificate:

Informant/Person In Charge Information:

Other Information & Instructions