

A certificate can be requested by the family or the funeral home
Request form and application process:
Governor's Memorial Certificate- State Form 54314
Completed forms faxed to: IVMC (812) 273-9221
Alan Burnham- Superintendent1415 North Gate Road
Madison, Indiana 47250
Phone: (812) 273-9220
Fax: (812) 273-9221
Email: IVMC@dva.in.gov