STATE OF TEXAS CERTIFICATE OF DEATH WORKSHEET

This information is required to complete the Death Certificate. Incomplete information will delay the filing of the Death Certificate. If you do not know the information write “Unknown”. You will be given a chance to complete the information prior to filing. This is the statement that is on the Death Certificate: WARNING – The penalty for knowingly making a false statement in this form can be 2 -10 years in prison and a fine of up to $10,000. (Health and Safety Code, Sec. 195, 1989)