Death Certificate Request Form

Any person who willfully or knowingly supplies false information on this form to be used for any purpose with the intent to defraud; willfully uses or attempts to use any certificate of birth or a copy of any record of birth knowing that such certificate was issued upon a record which was false or relates to the birth of another person may be fined not more than $10,000 or imprisoned for not more than five (5) years or both upon conviction. (Official Code of Ga, Pursuant to O.C.G.A., Chapter 31-10, Section 31