Form Vs-142.3 - Mail Application For Birth And Death Record
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1Bosque County Clerk
PO Box 617, Meridian Tx 76665
OFFICE USE ONLY
Cert #______________________
254-435-2201
Date: ______________________
county_clerk@bosquecounty.us
Issued by:___________________
Amount $___________________
MAIL APPLICATION FOR
Certificate/Book
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: Bosque County Clerk.
Birth Certificates
Death Certificates
Type
Cost X
# of
Total
Type
Cost X
# of
copies=
copies=
Total
$21
Standard Size
Long form
$23.00
Certified Copy (1 copy)
Optional USPS Express Return Delivery
Additional Copies
$4
$19.95
Total
Total
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
administered by the Office of Early Childhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Last Name
First Name
Middle Name
Full Name of
Person on Record
Date of Birth/Death
Month
Day
Year
Sex
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)
Applicant Name
Telephone #
Email Address
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 VALID PHOTO ID TO:
Bosque County Clerk
P.O. Box 617, Meridian TX 76665
VS-142.3 Rev. 06212016
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