APPLICATION FOR A DEATH CERTIFICATE
PLEASE READ THESE NOTES before completing this form.
Death Certificate
St Helens : SH/198/94
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 JOHNSON  DATE OF DEATH 1919
PLACE OF DEATH (Full address or name of hospital)
St Helens
FORENAME(S) Nellie
OCCUPATION  DATE OF BIRTH or AGE AT DEATH-
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,St Helens Registration Service, St Helens Town Hall, Victoria Square, St Helens WA10 1HP
I requireNUMBER death certificate(s)
5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
UK: applications should enclose an SAE with a Postal Order payable to : St Helens Council for £ 11.00
Overseas: applications should enclose a self addressed envelope and two IRCs, with payment by Postal Order payable to : St Helens Council
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.