Mail Application For Birth And Death Record
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1
2OFFICE USE ONLY
OFFICE USE ONLY
METHOD OF PAYMENT
CERT. # __________________________
CC __________
CCK/MO__________
RECEIPT # _______________________
ISSUED BY_______________________
MAIL APPLICATION FOR BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
MAKE CASHIER CHECK OR MONEY ORDERS PAYABLE TO: CITY OF AMARILLO
Birth Certificates
Death Certificates
# of
# of
Type
Cost X
Total
Type
Cost X
Total
copies =
copies =
Standard Size Long Form
$23
Certified Copy (1 copy)
$21
TOTAL AMOUNT
Additional Copies
$4
TOTAL AMOUNT
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part 1)
NAME ON RECORD
(NOMBRE)
FIRST (PRIMER)
MIDDLE (SEGUNDO)
LAST (APELLIDO)
DATE OF BIRTH/DEATH
SEX (SEXO)
M
F
(FRCHA DE NACIMIENTO/MUERTE
MONTH (MES)
DAY(DIA)
YEAR (ANO)
PLACE OF BIRTH/DEATH
(LUGAR DE NACIMIENTO/MUERTE
CITY (CIUDAD)
COUNTY (CONDADO)
STATE (ESTADO)
FULL NAME OF PARENT 1
FIRST (PRIMER)
MIDDLE (SEGUNDO)
LAST (APELLIDO)
(MADRE OR PADRE)
FULL NAME OF PARENT 2
(MADRE OR PADRE)
FIRST (PRIMER)
MIDDLE (SEGUNDO)
LAST (APELLIDO)
APPLICANT INFORMATION (Part 2)
APPLICANT NAME
TELEPHONE #
EMAIL ADDRESS
(NOMBRE DEL SOLICITANTE)
(TELÉFONO #)
(DIRECCIÓN DE CORREO ELECTRÓNICO)
MAILING ADDRESS
STREET ADDRESS (DIRECCION)
CITY (CIUDAD)
STATE (ESTADO)
ZIP (CODIGO POSTAL)
RELATIONSHIP TO PERSON NAMED ON RECORD
PURPOSE FOR OBTAINING THIS RECORD
(RELACIÓN CON LA PERSONA NOMBRADA EN EL REGISTRO)
(RAZON PARA OBTENER ESTE REGISTRO)
I AUTHORIZE MAILING TO THE ADDRESS BELOW. I HAVE VERIFIED THAT THE ADDRESS BELOW WILL RECEIVE MY ORDER.
(AUTORIZO EL CORREO A LA DIRECCIÓN ABAJO. HE COMPROBADO QUE LA DIRECCIÓN DE ABAJO RECIBIRÁ MI PEDIDO.)
NAME OF PERSON RECEIVING COPIES, IF DIFFERENT FROM APPLICANT
(NOMBRE DE LA PERSONA RECIBIENDO EJEMPLARES, SI NO ES EL SOLICITANTE)
MAILING ADDRESS FOR COPIES, IF DIFFERENT FROM APPLICANT
(DIRECCIÓN PARA CORRESPONDENCIA, SI NO ES EL SOLICITANTE)
CITY (CIUDAD)
STATE (ESTADO)
ZIP (CODIGO POSTAL)
PAGE 1 OF 2
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