Form Vs-142.3 - Mail Application For Birth / Death Record
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1OFFICE USE ONLY
City of Mission – Vital Statistics Department
th
1201 E. 8
Street
Date:
Mission, Texas 78572
(956) 580-8664 ph. / 580-8710 ph. / 580-8700 ph.
Cert #:
By
(956)580-8669 FAX /
MAIL APPLICATION FOR BIRTH / DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make money orders payable to: City of Mission - Vital Statistics. For any search of the files where a record is not found, the searching fee is not
refundable or transferable.
Birth Certificates
Death Certificates
Type
Cost X
# of
Total
Type
Cost X
# of
copies=
copies=
Total
Certified Copy - Long form
$23
Certified Copy (1 copy)
$21
Additional Copies
$4
Total (Money Order payable to City of Mission)
Total (Money Order payable to City of MIssion)
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Last Name
First Name
Middle Name
Full Name of
Person on Record
Month
Day
Year
Sex
Date of Birth/Death
Place of
City or Town
County
State
Birth/Death
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent 1
Maiden Name/Last Name
First Name
Middle Name
Full Name of
Parent 2
APPLICANT INFORMATION (Part II)
Email Address
Applicant Name
Telephone #
Full Mailing Address
Street Address
City
State
Zip
Purpose for obtaining this record:
Relationship to person listed above
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF
COUNTY OF
Before me on this day appeared
(Applicant name)
now residing at
(Address)
(City)
(State)
who is related to the person named on Part I as
and who on oath deposes and says that the contents of this
affidavit are true and correct.
(Relationship)
The applicant presented the following type and number of identification:
Applicant Signature
Sworn to and subscribed before me, this
day of
, 20
.
(Seal)
Signature of Notary Public and Notary ID Number_
Typed or Printed Name:
Commission Expires:
Street Address:
City, State, Zip:
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
MAIL THIS APPLICATION, PAYMENT AND A PHOTOCOPY OF VALID ID TO:
City of Mission – Vital Statistics
th
1201 E. 8
St., Mission, TX 78572
VS-142.3
(Rev.10/2016)
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