APPLICATION FOR A DEATH CERTIFICATE PLEASE READ THESE NOTES before completing this form.

Death Certificate Bolton : GBL/9/107

1 TO BE COMPLETED BY THE APPLICANT Name of applicant Mr Mrs Miss/Ms (STATE NAME IN FULL) Full postal address   Post Code: Telephone no: e-mail address:

2 Please state your relationship to the person to whom the certificate relates:

3 DETAILS OF DEATH CERTIFICATE REQUIRED
SURNAME OF DECEASED MORRIS	DATE OF DEATH 1908
	PLACE OF DEATH (Full address or name of hospital) Great Bolton and Lever
FORENAME(S) Phoebe
OCCUPATION	DATE OF BIRTH or AGE AT DEATH62
HOME ADDRESS	If a married woman, please give name and surname of husband

4 REQUIREMENTS	Send this Application to:
DEATH CERTIFICATE £11.00	Superintendent Registrar, Bolton Register Office, Albert Halls, Victoria Square, Bolton, BL1 1RU
I requireNUMBER death certificate(s)

5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
UK: applications should enclose an SAE. Postal order or cheque made payable to : Bolton MBC for £ 11.00 Overseas: applications should enclose a self addressed envelope and two IRCs, with payment by Bankers Sterling Draft payable to : Bolton MBC Please note: Bolton RO will add a 1.5% supplement for Credit Card Orders.
If paying by Credit Card: Please debit my account by the amount: £		Type of card (e.g. Visa, Mastercard or Switch):
Name on Card:		Card Expiry Date (DD/MON/YYYY):
Enter both Card Number & Security Code. Card Number:                                       Security Code:
Signature:   Date:   Card Issue No. : (Switch only) Card Start Date (DD/MON/YYYY): (Switch only)
The Fee for a certificate issued against this form 'as printed' will not be refunded. You are strongly recommended to add any qualifying information you may have in order to help the registrar issue the correct certificate.