Nevada Birth Certificate Application printable pdf download

Nevada Birth Certificate Application

State of Nevada Health Division

Bureau of Health Statistics Planning, Epidemiology and Response

Office of Vital Records and Statistics

4150 Technology Way, Suite 104

Carson City, Nevada 89706

Telephone (775) 684-4242

BIRTH CERTIFICATE APPLICATION

$20.00 for one certified copy

Number of copies____________

$10.00 Search/Verification of a record (search/verifications do not include a certified copy. Choose this

option if you are only wanting verification that the record is on file with Nevada Office of Vital Records)

Check, or Money Order, made payable to Vital Records

______________________________________________________________________________

PHOTOCOPY OF APPLICANT’S ID /DRIVERS LICENSEAND

PAYMENT IN FULL IS REQUIRED TO OBTAIN CERTIFICATE

Full name at birth:

First

Middle

Last

Date of birth: _________________________________________________________________________

Place of birth: _________________________________________________________________________

Father’s name: _________________________________________________________________________

____________________________________________________________

Mother’s maiden name:

NRS 440.650 and NAC 440.070 require that a relationship or a need to facilitate a legal process be established in

order to receive a certified copy of a record.

Please state your relationship and your legal need for this record:____________________________________

_______________________________________________________________________________

Signature of applicant: __________________________________________________________________

Phone number: ________________________________________________

Your name and address (please print): _____________________________________________

_______________________________________________________________________________

FOR OFFICE USE ONLY

Amount received: _______________________ Receipt number: _________________________

No. of copies issued: ______________________ Date: ______________________

(Rev.01/31/2013)

Nevada Birth Certificate Application