Waseca CO Historical Society
                                 PO Box 314
                              Waseca, MN  56093


	I am requesting an Uncertified copy of death record for:

(Please Print)

1. Name: ________________________________

   Date: _______________

   Book    Page     Line

   ______  ______   ______

2. Name: ________________________________

   Date: _______________

   Book    Page     Line

   ______  ______   ______

3. Name: ________________________________

   Date: _______________

   Book    Page     Line

   ______  ______   ______

	Enclosed is $2.50 for each copy requested and a self addressed, 
stamped envelope (for the return of the records).

Thank you,

_____________________________

(Please Print)
Your Name: ____________________________

Address:   ____________________________

           ____________________________


____ Check here if you would like information on joining the 
     Waseca Historical Society


                                                   Office use only:
                                                   Date Rcd: _______________
                                                   Date sent: ______________

                             USGenweb-MNArchives- Sept2000