Mail-In Application For Certified Copy Of Birth Or Death Certificate Form 2015

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Sherry Lemon, County Clerk/Local Registrar, Wise County
200 N. Trinity • P.O. Box 359 • Decatur, TX 76234 • (940) 627-3351
sherry.lemon@co.wise.tx.us
MAIL-IN APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
DEATH- NUMBER REQUESTED
BIRTH- NUMBER REQUESTED
_____$21.00 First Certified Copy
_____$23.00 Each Certified Copy
_____$4.00 Each Additional Copy
Make check or money order payable to: Wise County Clerk.
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID AND SWORN STATEMENT WHEN SENDING
THE REQUEST.
1.Full Name of
First
Middle
Last
Person on Record
Month
Day
Year
Sex
2.Date of Birth/Death
3.Place of Birth/Death
City or Town
County
State
4.Full Name of
First
Middle
Maiden Name/Last Name
Parent 1
First
Middle
Maiden Name/Last Name
5.Full Name of
Parent 2
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
administered by the Office of Early Childhood Coordination of Health and Human Services.
7.
Applicant’s Name: ____________________________________________ 8. Phone Number_____________________________
9
__________________________________________________________________________
. Mailing Address: __
Street Address
City
State
Zip
____________________
10. Relationship to Person in Item 1: ______________________11. Purpose for obtaining this record:
I authorize mailing to the address below. I have verified that the address below will receive my order and receipt.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM
OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY
CODE, CHAPTER 195, SEC. 195.003)
__________________________________________
_________________________________
Signature of Applicant
Date
MAIL THIS APPLICATION, PAYMENT, SWORN STATEMENT AND PHOTOCOPY OF YOUR VALID ID TO:
SHERRY LEMON, WISE COUNTY CLERK
P.O. BOX 359
200 N. TRINITY
DECATUR, TX 76234
(APPLICATIONS WITHOUT PHOTO ID AND THE ATTACHED SWORN STATEMENT WILL NOT BE PROCESSED)
The in-person application is a different form and is available in the County Clerk’s office and does not require notarization.
FOR OFFICE USE ONLY
Deputy_______________
Certificate #____________
Type of ID_________________
ID# _____________________
Rev. 9/2015
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