Date: __________________________________________

Name of Person: ______________________________________________________ 

Date of Death: _____________________________________________________

Type of Record (from website listing) ____________________________________

Applicant's relationship to person: ______________________________________ 

Mail original record to: 
*Your name and address will be available to future researchers/applicants 

____________________________________________________________________
Name 

____________________________________________________________________
Street Address or Post Office Box 

____________________________________________________________________
City State Zip Code 

Processing this request and mailing of record may require six weeks. 
Some of the records have already been distributed to the descendants. 
Xerox copies of original birth recordswill be kept in the possession 
of the Society and are available if the original has previously been distributed. 

Previous applicant/recipient: ___________________________________________
Address: _________________________________________________________
              _________________________________________________________
Date received: _____________________________________________________