Fillable Certificate Of Identity For Birth-Death Form printable pdf download

Certificate Of Identity For Birth-Death Form

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County of Stanislaus

Office of the Clerk-Recorder

CERTIFICATE OF IDENTITY STATEMENT

I,________________________________________________, swear under penalty of perjury under the laws of

(Printed Name)

the State of California, that I am an authorized person, as defined in California Health and Safety Code Section 103526(c) ,

and am eligible to receive an Authorized Certified Copy of the birth or death record of the following individual(s):

Name of Person Listed on Certificate (Registrant)

State Your Relationship to the Person Listed on Certificate

Sworn this _________ day of __________________, 20____, at ________________________, ___________,

(Day)

(Month)

(City)

(State)

_____________________________________________

(Signature)

NOTE

: If submitting your order by mail or messenger, you must have your sworn statement notarized

using the Certificate of Acknowledgment below.

-----------------------------------------------------------------------------------------------

CERTIFICATE OF ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the

document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of_____________________

County of ___________________

On_________________, before me, _______________________________________________, personally appeared

(date)

(printed name and title of officer authorized to take acknowledgments)

_______________________________________ who proved to me on the basis of satisfactory evidence to be the

(print name of person )

person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the

same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument, the person(s), or the

entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under

the laws of the State of California that the

foregoing paragraph is true and correct.

WITNESS my hand and official seal.

______________________________________

NOTARY SIGNATURE

Notary Seal

Certificate Of Identity For Birth-Death Form

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