Wayne County, Michigan

WAYNE COUNTY CLERK
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FULL NAME OF DECEASED [First, Middle, Last]

DATE OF DEATH [Month, Day,Year]		CITY OF DEATH *excluding Detroit - Deaths taking place within the City Limits of Detroit are recorded by the :: city of detroit health dept. » ::

	Applicant's Name

	Address

	City, State, Zip

	Phone [Area Code + Number]

	Applicant's Signature [Name as it is now] Date

Please send the following: _____ FIRST CERTIFIED COPY $22.00 _____ Additional certified copies [each] $7.00 [same record] _____ Record Search [each] $3.00 [same record] _____ TOTAL COST
Make money order, cashier's check, or certified check [no personal checks] payable to :
	Wayne County Clerk c/o Birth and Death Records Division 201 Coleman A. Young Municipal Cntr Detroit, MI 48226