Application Death Record Form - Kerr County
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1Jannett Pieper,
Kerr County Clerk
For Office Use Only
For Office Use Only
700 Main St, #122
Cert. #____________
Remit No. _____________
DOCUMENT CONTROL#
Amount $______________
Kerrville, Texas 78028
________________________
Cash
Check
Tel: (830) 792-2255
Date: _________ By: _______
Fax: (830) 792-2274
By: __________
jpieper@co.kerr.tx.us
Application Death Record
DEATH
DONATION
Yes,
Amount Requested
I wish to make a voluntary contribution
of $5 to promote healthy early childhood
____ 1 Certified Copies $21.00
by supporting the Texas Home Visiting
____ Extra Copies of same record
Program. (This fee is sent to the State
@ $4.00each.
and not kept in Kerr County)
Please Print
1. Full Name of
First Name
Middle Name
Last Name
Person on Record
2. Date of
Month
Day
Year
3. Sex
Birth or Death
4. Place of
City or Town
County
State
Death
5. Full Name
First Name
Middle Name
Last name
of Father
6. Full Maiden
First Name
Middle Name
Maiden Name
Name of Mother
7. Your Name:
_________________________________ 8. Telephone: (
) ______________
(person filing out the form)
9. Your Mailing Address: ______________________________ City: ___________________State/Zip: _____________
10. Relationship to person named in Item 1 above: _________________________________________________________
11. Purpose for obtaining this record: ___________________________________________________________________
12. Social Security Number of Deceased __________________ Birth Date _________ Birth Place: _________________
For any search of the files where a record is NOT found, the search fee is non-refundable or transferable.
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM CAN BE 2-10
YEARS IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC 195.003)
Death records are confidential for 25 years, therefore, issuance is restricted. Other records may be obtained when sufficient
information for identification is provided.
Administrative rules require that on restricted records, all identifying information must be provided in order to issue such record being
requested along with a Xerox copy of the identification from the person requesting the record.
Your Signature: _____________________________
Date of Application: _______________________________
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