Instructions to apply for an INFORMATIONAL copy of a Death certificate 1. Complete the form below for each Death certificate you are requesting. 2. Send the form with a check or money order for $21.00 for each certificate to: Inyo County Recorder PO Box F Independence, CA 93526 Information of deceased Number of copies requested @ $21.00 each _______ Name on certificate – First

Middle

Last

Date of death

Place of death – City or Town

Father’s name

Sex

Place of death - County

Mother’s maiden name

Information of person requesting the certificate Printed name of person completing Date application

Telephone number

Address – Number, Street or P. O. Box

City

State

Zip code

Mailing address for copies if different from above

City

State

Zip code

Signature of applicant