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PLC:

a0019u

Agency:

clare county treasurer

For:

clare county medical examiner

Phone:

989-539-7801

Address:

225 w. main st.
harrison, michigan 48625

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*Company Name:

*Phone #:

(### - ### - ####)

*Fax #:

*Name of Deceased:

*Date of Death:

(Month / Day / Year)

Notes:

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Payment Amount :

Subtotal:

$0.00

Total:

$0.00

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*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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