Request Form
Death Certificate
Wethersfield Town Clerk
Fee: $20.00
Driver’s License of Person Requesting Copy is Required
Availability of a certified copy of a death certificate is based upon the town
of occurrence and/or town of residency of the deceased
Death Certificate Information
Name of Deceased: ____________________________________________
Date of Death __________Place of Death (Town):______________________
Date of Birth: ___________Place of Birth (Town): _______________________
Father’s Name__________________________________________________
Mother’s full maiden name_________________________________________
If married, spouse’s name_________________________________________
Person Making This Request
Name: ________________________________________________________
Address: ______________________________________________________
City/State/ Zip Code: _____________________________________________
Phone Number: _________________________________________________
Relationship to deceased: _________________________________________
Signature ______________________ Date__________________________
Enclose a copy of the driver’s license of the person who is requesting the
certified copy, this form and a check for $20.00 for each certified copy, made
payable to the Wethersfield Town Clerk, 505 Silas Deane Highway, Wethersfield,
CT 06109.
