Mail Application Form For Certified Copy Of Birth Certificate - San Joaquin County Phs
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2San Joaquin County Public Health Services
Mail Application for Certified Copy of Birth Certificate
Effective July 1, 2003 California law permits only authorized individuals to receive authorized
certified copies of birth records required to establish identity and related uses such as obtaining
a driver’s license, passport, or insurance coverage. If you are requesting an authorized certified
copy, complete all application sections and submit it with a notarized statement as described in
section 4.
An informational certified copy may be obtained by any person but cannot be used to establish
formal identity. If you are requesting an informational certified copy, complete sections 1 and 2
only and submit the application. A notarized statement is not required for an informational only
copy.
The health department furnishes certified copies for births that were
registered during the current and past calendar year only.
Submit this application form with the appropriate fees to:
Public Health Services – Vital Records Unit
PO Box 2009 Stockton, CA 95201-2009
Permanent records are kept at the County Recorder’s Office at:
nd
44 N. San Joaquin St. 2
floor Ste. 260
Stockton CA 95202
Certificate Type Requested: ___ Authorized Certified Copy ___Informational Only
Number of Certificates Requested ______
1. Newborn/Registrant Information
Name ___________________________________________ Birth Date___/___/___
Multiple Births – Additional Newborns (twins/triplets)
Name ___________________________________________
Name __________________________________________
Place of Birth _______________________ Mother’s Maiden Name_______________
2. Requestor Information
Name________________________________________
Mail Address___________________________ _______________ _____
________
Number and Street
City
State
Zip Code
3. Authorized Individual Information – Complete this section if requesting authorized
certified copy. Specify which category of authorized individual you are:
A parent, legal guardian, grandparent, or sibling of the registrant.
A party entitled to receive the record as a result of a court order; an attorney or a licensed
adoption agency seeking the birth record to comply with Section 3140 or 7603 of the Family
Code.
A member of a law enforcement agency or representative of another governmental agency,
as provided by law, who is conducting official business.
An attorney representing the registrant or registrant’s estate; a person or agency
empowered by statute or appointed by a court to act on behalf of the registrant or his/her
estate.
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