P ALLANTE
CENTER for
ITALIAN
RESEARCH

DOCUMENT SERVICE - ITALY

DEATH RECORD


Use this form to request a certificate (genelogical extract) of an Italian death record,
which will be forwarded from Italy. Use this form when you know the names, date and place.

Please sign: I understand that I am paying a nonrefundable fee to "request a search" and
there is no guarantee the document(s) requested will be found. (Occasionally, the document requested may not exist). _____________________

Place of Death (town): ______________ Province_______________
If you do not know the town name, you must use Form B. Name of Your Ancestor: _____________________________ Male___Female___
Maiden surname (before marriage) if female:___________________
Name of Your Ancestor's Spouse: ______________________
Your Ancestor's Father: ______________________
Your Ancestor's Mother: ______________________(maiden surname before marriage)____________
Date of Death: Day____Month_________Year_____
If extact date is unknown choose a range of 3 years to search: From _______ to _______.

If you do not know the exact date, you must know name of spouse or parents, as there could be more
than one person by the same name in your ancestral village.

Source of your date information: ______________________________________________________
(Is it from specific documents you’ve found, family stories, or a calculated guess?)

After 8 weeks, if the search is reported "negative" or there's been no response from the Italian archives office (which usually means "not found"),
submit a new request with a new range of dates, name variation, or town name.

WHERE SHOULD WE SEND THE RESULTS OF THE SEARCH? (Please print neatly)
Name: ___________________________________
Address: _________________________________
Postal Code: ______________________________
Country: _________________________________
Email: ___________________________________

THANK YOU FOR YOUR ORDER. **Please enclose a self-addressed, stamped envelope. Allow 6 to 8 weeks.

PAYMENT METHODS: Credit Card (USA residents only): VISA, Mastercard, American Express, Discover. (Print clearly!)
Expiration date: (Month & Year) ___/___ Security Code _ _ _ _
Account Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Name on card: __________________________________Authorizing Signatue: ______________________________________

Personal Check (USA residents): payable to "Pallante Center" or use Paypal.com (use email debhill@capital.net).

Outside USA: Intn'l postal money order (at your local post office) or Intn'l bank draft (at your local bank).

Mail this form to:

Pallante Center for Italian Research
Documents - Italy
P.O. Box 4664
Queensbury, NY 12804
USA