Census of Fatal Occupational Injuries - State, local, and tribal government

FAX requesting death certificates Attachment 2C

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State letterhead

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FAX TRANSMISSION

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This document and any attachments are confidential and intended solely
for the individual or entity to whom they are addressed. If you have
received this fax in error, destroy it immediately.

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Date:

Please deliver to: [Name, address, fax, and phone]

Total number of pages including this sheet: __________

Please fax or mail Death Certificates for the persons listed below to:

[ Name, address, fax, and phone of CFOI state agency ]

Thank you for your time.

[Name of CFOI contact]

Name SS# Date of death

John Doe xxx-yy-zzzz mm/dd/yyyy

Jane Smith yyy-xx-aaaa mm/dd/yyyy

End of list