Form Center

Death Certificate Request

2. East Chicago Health Department
   Vital Records Section
   100 W Chicago Avenue
   East Chicago, IN 46312
   
4. Application for Search & Certified Copy of Death Record
6. Disclaimer*
   These certificates are only generated for individuals whom have passed in the city of East Chicago.
8. Please note, death records in the state of vital records office begin in 1900
   Death registration in East Chicago began in 1927. Prior to 1900, records of death are filed only with the Local Health Department in the county where the death actually occurred.
   
   There are no indexes to the state health for death certificates from 1900 through 1918.
10. Identification of the requester is required. Please do not send the originals in the mail.
12. Name of the Deceased
14. Date of Death
    Date of Death
15. Still birth?

    1. Yes
    2. No
17. Place of Death - City
18. Place of Death - County
20. Search Fee
    Search Fee Start Date

    —

    Search Fee End Date
    A search fee of $12 will be administered if the exact date of death is not known. Please indicate the 5 year period to be searched.
    
    An additional $12 is required for each additional 5 year period search.
    
    Search fees are not refundable.
22. Date of Birth of the Deceased (If Known)
    Date of Birth of the Deceased (If Known)
24. Father's Name
25. Mother's Maiden Name
27. Relationship to the Person on Record
29. Purpose for Which This Record Is Being Used
31. Electronic Signature Agreement
33. Address
35. City
36. State
37. Zip Code
39. Phone Number
41. Total Certificates
    Fees: $12
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42. Print Only

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