Texas Department Of State Health Services Application For Certified Copy Of Birth Or Death Record Page 2
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2INSTRUCTIONS FOR APPLICATION FOR CERTIFIED COPY OF A BIRTH OR DEATH RECORD
Check the appropriate box either a Birth or Death record.
Indicate the number of records requested and compute the amount of money to be sent. PLEASE DO NOT SEND
CASH THROUGH THE MAIL. WE SUGGEST YOU SEND WITHER A PERSONAL CHECK OR MONEY ORDER
MADE PAYABLE TO: DSHS – VITAL STATISTICS.
Item 1.
Name of Record:
State the FULL NAME of the person shown on the record being requested.
Item 2.
Date of Event: (The date of the birth OR death.)
Give the exact date of the birth or day the person died. (If you do not know that exact date of death,
then give the date the person was last known to be alive.)
Sex:
Check the appropriate box, male or female.
Item 3.
Place of Event:
State the name of the city or county in which the birth or death occurred. (If you do not know the
exact place of death, show the last address known when the person was alive).
Item 4.
Father’s Name:
Give the full name of the father of the person shown on the record.
Item 5.
Mother’s Maiden Name:
Give the FULL MAIDEN NAME of the mother of the person shown on the record.
Item 6.
Applicant’s Name:
GIVE YOUR full name.
Item 7.
Telephone Number:
Give is a telephone number with area code where you can be reached between the hours of 8 am
and 5 pm, Monday through Friday.
Item 8.
ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE:
This additional information assists our staff in positively identifying a record when exact date, places
and spelling of the name (s) are not known for a death certificate:
Social security Number of the deceased
Birthdate of the deceased
Birthplace of the deceased
Any other information that would be helpful in identifying the record of an individual
Item 9.
Mailing Address:
Give is your complete current mailing address.
Item 10.
Relationship to person named on the record:
State how you are related to the person whose record you requesting.
Item 11.
Purpose for obtaining the record:
State the reason or purpose for which you are requesting the record.
SIGN AND DATE THE APPLICATION. ENCLOSE A PHOTOCOPY OF YOUR ID WITH A PICTURE ON IT
(PHOTOCOPY OF PICTURE ID). MAIL TO ADDRESS AT TOP OF APPLICATION FORM WITH THE CORRECT
FEE (S).
VS-141 REV. 12/2005
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