Center for Health Statistics
THIS IS A PERMANENT RECORD — PLEASE TYPE OR PRINT ONLY
PLEASE FURNISH INFORMATION AS TAKEN FROM ORIGINAL BIRTH RECORD.
THIS INFORMATION IS NECESSARY TO LOCATE THE ORIGINAL BIRTH CERTIFICATE.
1. Name of child — First
2. Date of birth
3. Name of physician, if known
4A. Place of birth — Hospital
4C. State (if not in U.S.A., name country)
5. Name of mother — First
6. Name of father — First
7. U.S. citizenship — Was natural mother a U.S. citizen when child was born?
8. U.S. citizenship — Was natural father a U.S. citizen when child was born?
9. Was the child listed above previously adopted in the united states?
10. State/County of adoption:
If yes, please complete item #10.
PLEASE ENTER INFORMATION BELOW AS IT IS TO APPEAR ON THE NEW BIRTH RECORD.
If any information is left blank, it will be blank on the birth certificate.
All information requested below MUST be provided or a new birth certificate cannot be completed for filing.
11. Current legal name of mother/parent A — First
11A. Legal/Maiden name at birth of mother/parent A — First
Last name at mother’s birth/maiden name
12. Date of birth
13. State of birth (if not in U.S.A., name country)
14. Social Security Number
15. Mother’s residence at time of child’s birth
15A. Residence street address
15B. State (if not in U.S.A., name country)
15E. Zip code
15F. Inside city limits?
16. Name of father/parent B — First
17. Date of birth
18. State of birth (if not in U.S.A., name country)
19. Social Security Number
20A. If adoptive person is an adult, is new birth record to be issued?
20B. Is this a step-parent adoption?
20C. Is this a single-parent adoption?
21. Agency or person through which child was obtained
22A. Name (print or type)
22B. Mailing address
23A. Current mailing address
The clerk of the court should require that as much of the information as is available in parts I and II
be completed before certification is made and the report mailed to the registrar of vital statistics.
24. I hereby certify that an adoption decree was filed on the
25. Adopted name of child as set forth in decree
26. Signature of
Clerk of court
The $35 fee for amendment of Oregon birth certificate may be submitted with this form.
The $35 fee does not include a certified copy of the new certificate.
One short-form certificate is $25.
One full-image, long-form certificate is $30 (available for 1903-2007).
Mail to: Center for Health Statistics, P.O. Box 14050, Portland, Oregon 97293-0050