Proviso Township | Death Record Request Form

Proviso Township Clerk Department of Vital Records 4565 Harrison St., Hillside, IL 60162 Telephone: (708) 449-4303 – Website: provisotownship.gov

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Deceased's Name:

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Date of Death:

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Place of Death (City or Village in Proviso Township):

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I, THE UNDERSIGNED DO HEREBY CERTIFY THAT I AM A PERSON, OR A DULY AUTHORIZED AGENT OF A PERSON, WHO HAD THE PERSONAL OR PROPERTY RIGHT INTEREST IN THE DEATH CERTIFICATE, AND AM LEGALLY ENTITLED TO THE CERTIFICATE, AS SPECIFIED BY LAW (410 ILCS 535/5 [4] [D]).

Confirm you are legally entitled to the certificate and the above statement is accurate:

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Your Name:

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Mailing Address:

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Confirm mailing address:

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Phone number:

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Please confirm phone number:

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Relationship to Deceased:

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BY TYPING YOUR NAME BELOW, THE REQUESTOR AGREES TO THE TERMS AND CONDITIONS OUTLINED IN THIS REQUEST. NON-COMPLIANCE MAY RESULT IN THE DENIAL OF REQUEST. ELECTRONIC/TYPED SIGNATURE IS EQUIVALENT TO AN ORIGINAL SIGNATURE AND IS EVIDENCE THAT YOU AGREE TO BE BOUND BY THIS.

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Price: 1st certified death certificate $13.00
Additional $4.00

Requesting a call-back for a phone payment (Have your debit or credit card information ready)

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Proviso Township | Death Record Request Form

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