Application For Certified Copy Of Birth/death Certificate - Desoto Parish
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1APPLICATION FOR CERTIFIED COPY
OF BIRTH/DEATH CERTIFICATE
Short-Form Birth Certification Card
# Copies Requested:_____ @ $14.00 each =$ ________
Long-Form Birth Certificate
# Copies Requested:_____ @ $24.00 each =$ ________
Death Certificate
# Copies Requested:_____ @ $16.00 each =$ ________
Total Fees Due $____________
Name at Birth/Death:
_____________________________
_____________________________
_____________________________
First Name
Middle Name
Last Name
__________________ _________
______________________________
_____________________________
Date of Birth/Death
Sex
City of Birth/Death
Parish of Birth/Death
Father’s Name:
_____________________________
_____________________________
_____________________________
First Name
Middle Name
Last Name
Mother’s Full Maiden Name before Marriage:
_____________________________
_____________________________
_____________________________
First Name
Middle Name
Maiden
Relationship to Person Named on the Certificate (Must Submit Photo ID)
Self
Father
Grandparent
Sister
Legal Guardian
Mother
Child
Grandchild
Brother
Current Spouse
Other
Applicant Information:
_____________________________
_____________________________
_____________________________
First Name
Last Name
Day Phone
_____________________________
_____________________________
_____________ _______________
Residence Address
City
State
Zip Code
_________________________________________________
Deliver in Person
Please Print completed form, Sign and
to the DeSoto Parish Clerk's Office
Signature
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