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CITY OF ORANGE - VITAL STATISTICS

P.O. BOX 520

FLOOR CITY HALL

ORANGE, TX 77631

803 W. GREEN AVE.

PHONE (409)883-1081 FAX (409)988-7315

ORANGE, TX 77630

APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE

PLEASE PRINT

1. Full Name of Person on Record (F/M/L) _________________________________________________________________________

2. Date of Birth or Death (Month/Day/Year) ___________________________________________ 3. Sex _____________________

4. Place of Birth or Death (City) ___________________________________ (County)_______________________________________

5. Father’s Full Name (F/M/L) ___________________________________________________________________________________

6. Mother’s Full Name (F/M/L) __________________________________________________________________________________

7. Applicant’s Name:_______________________________________________8. Telephone #________________________________

9. Relationship To Person Named in Item 1.:_________________________________________________________________________

10. Purpose For Obtaining This Record: ______________________________________________________________________________

11. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE.

Social Security # of Deceased_________________________________________________________________________________

Birth Date ____________________________________ Birth Place _________________________________________________

Remote BIRTH

DEATH

______ # of copies X $22.00 = ________

______ # of copies X $20.00 = _________

______ # extra copies X $22.00 = ______

______ # extra copies X $ 3.00 = _______

Total Enclosed = __________

Total Enclosed = ___________

_______ Please Mark if needed for a Passport. It is possible a Long Form will be required by the Passport office to obtain your

passport. Please let a clerk know, they can instruct you further. We only have long forms for persons born in the City of Orange. You

would be required to obtain the long form from your place of birth.

______ # of copies X $22.00 = ___________

Election ID Certificate = $2.00

THIS IS ALLOWED ONCE IN YOUR LIFETIME.

This EIC can only be used at DPS to obtain your voter registration ID. It cannot be used for other identification purposes.

Only the person seeking an Election ID Certificate can obtain their own birth certificate. No family member or otherwise

qualified applicants will be able to obtain a birth certificate subject to the reduced fees on behalf of other persons.

I attest that I am applying for an Election ID Certificate for myself and I have never applied before.

X______________________________________________________________________ Date:_______________

WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A

For any search of the files where a record is not

FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)

found the fee becomes a searching fee and is non-refundable or transferable. Birth records are confidential for 50 years and death

records for 25 years; therefore, issuance is restricted.

Please attach a photocopy of ID to completed application and pay the fee.

Signature of Applicant: X________________________________________________________ Date _____________________________

_____Please Mail To Address:________________________________________________________________________________________

Application For Certified Copy Of Birth Or Death Certificate - City Of Orange - Vital Statistics

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