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

Census of Fatal Occupational Injuries

Attachment 2C - FAX requesting death certificatesAttachment 2C

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

OMB: 1220-0133

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FAX requesting death certificates Attachment 2C


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State letterhead



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FAX TRANSMISSION


**********************************************************************

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.

**********************************************************************


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




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKincaid, Nora - BLS
File Modified0000-00-00
File Created2021-01-15

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