MEMORANDUM - Louisiana Department of Health
Devin George, State Registrar
Bureau of Vital Records and Statistics
P.O. Box 60630
New Orleans, LA 70160
Health Unit: ______________________
Registrar: ______________________
Phone Number: ______________________
Fax Number: ______________________
Subject: Monthly Banknote Reconciliation for Month of ______________________
Death Certificate Banknote Paper
Beginning Audit # ______________________
Ending Audit #: ______________________
Number of Death Certificates Sold @ $9.00: ______________________
Number of Death Certificates Sold @ $7.00: ______________________
Total Number of Certificates Issued: ______________________
Number of Certificates Voided: ______________________
The above represents an accurate accounting of banknote stock used and fees collected. The number of voids have been counted and verified, and all voids are attached.
Signature___________________________ Parish ______________________________
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Mail Completed Form and Voided Banknotes To:
Vital Records
Attn: Field Representatives
PO Box 60630
New Orleans, Louisiana 70160
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