Application For Birth/death/marriage Certificate Form

(CASHIER’S CHECK OR MO ONLY)

_____________

Cert #

Birth Record

$23.00 EA (SEARCH FEE)

ST

Date ______________

Death Record $21.00 1

COPY (SEARCH)

($4.00 EA ADDL-SAME PERSON)

# of Copies _________

Marriage Record $21.00 EA(SEARCH FEE)

Janette K. Green

Palo Pinto County Clerk

APPLICATION FOR BIRTH/DEATH/MARRIAGE CERTIFICATE

WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY

MAKING A FALSESTATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE

STATEMENT IS 2 TO 10 YEARS IMPRISONMENT ANDA FINE OF UP TO $10,000. (HEALTH AND SAFETY

CODE, CHAPTER 195, SEC. 195.003)

APPLICATIONS WITHOUT A COPY OF YOUR PHOTO ID & NOTARY JURAT WILL NOT BE PROCESSED

BIRTH:

Name:___________________________________________________________________

(Last)

(First)

(Middle)

Date of Birth:___________________________________________________

Place of Birth:__________________________________________________

(City or Town)

(County)

(State)

Full Name of Parent 1:______________________________________________________

(Maiden Name/Last Name)

(First)

(Middle)

Full Name of Parent 2:______________________________________________________

(Maiden Name/Last Name)

(First)

(Middle)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________

DEATH:

Name:_________________________________________________________

(Last)

(First)

(Middle)

Date of Death:__________________________________________________

Place of Death:_________________________________________________

(City or Town)

(County)

(State)

________________________________________________________________________________________________________________________________________________________________________________________________________________________

MARRIAGE: Applicant #1 Name:_____________________________________________________________

(Maiden Name/Last Name )

(First)

(Middle)

Applicant #2 Name:_____________________________________________________________

(Maiden Name/Last Name)

(First)

(Middle)

Date of Marriage:______________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

□ 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 the Health and Human Services

NOTICE: Applicant must be qualified to obtain the birth/death record in accordance with Section 181.1, Chapter 25, Texas Administrative Code,

i.e., the registrant or immediate family member either by blood, marriage or adoption, his or her legal guardian, or his or her legal

agent or representative.

STATE RELATIONSHIP TO ABOVE: (Spouse, Sibling, Parent, Child, Self) ________________________

PURPOSE FOR OBTAINING RECORD: _______________________________

Applicant Signature

Phone #

: _________________________________________

: _____________________

**By signing here, the applicant acknowledges understanding of and compliance with the statute cited above AND agrees to pay the search fee

in the event no vital record is found

Complete Address

: _________________________________________________________________________________

SEE PAGE 2 FOR NOTARY JURAT

(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)