City of Ashtabula, Ohio

Death Certificate Request Form

Please provide the following information:

Name of Deceased 
Date of Death
Print Name of Person Making Request

Address of Person

Making the Request

Zip/Postal Code
Contact Phone #

Signature of Person

 Making the Request

Print this form, sign it and mail along with a check for $25.00 and a self-

addressed stamped envelope to:

 

Ashtabula City Health Department

4717 Main Avenue

Ashtabula, Ohio 44004

                                        OR

We now accept Visa & Mastercard.  

 

Print this form, sign it and fax it to 440-992-7163 along with a copy of your

credit card and signature and the information below: 

 

                                               VISA   MASTERCARD   DISCOVER

 

                            Account #   Expiration 3 digit "V" code from back of card

 

Name on Card:
Full Address of Cardholder: Street Address:
City/State/Zip:
Telephone # of Cardholder:

Signature of Cardholder:

* By signing this you are authorizing the City of Ashtabula to debit your account for the charges due.

 

 

*To pay by Credit Card,

You must fax a copy (front & back) of your credit card

Along with this Form.*

 

There is a $3.00 convenience fee on use of credit card.

 

You will be charged $25 for the certified copy, $3.00 convenience fee on use of credit card,  and postage.

 

Please check the type of postage you prefer

 

   Regular Mail $0.45*  Priority Mail $5.15*   Express Mail $18.95*

 

*These fees are charged according to what the USPS is charging at the

  time of the order.