APPLICATION FOR A DEATH CERTIFICATE
PLEASE READ THESE NOTES before completing this form.
Death Certificate
Flintshire (Mold) : HAW/03A/6
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   DATE OF DEATH
PLACE OF DEATH (Full address or name of hospital)
Hawarden
FORENAME(S)
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, Flintshire Register Office, Llwynegrin Hall, Mold, Flintshire. CH7 6NR. UK
I requireNUMBER death certificate(s)
5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
UK: applications should enclose an SAE. Postal order or cheque made payable to : Flintshire County Council for £ 11.00
Overseas: applications should enclose a self addressed envelope and two IRCs, with payment by Bankers Sterling Draft payable to : Flintshire County Council