Death Certificate Request Form - Austin/travis Co. Health And Human Services Dept.
Download a blank fillable Death Certificate Request Form - Austin/travis Co. Health And Human Services Dept. in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Death Certificate Request Form - Austin/travis Co. Health And Human Services Dept. with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1- - - MAIL - IN APPLICATION -- MUST BE NOTARIZED - - -
Office of Vital Records
Austin/Travis Co. Health and Human Services Dept.
PO Box 1088, Austin, TX 78767-1088
Doc# _________________
Phone (512) 972-4784 / Fax (512) 972-5208
State# ________________
REQUESTS MUST INCLUDE COPY OF VALID GOVERNMENT-ISSUED IDENTIFICATION
(Mail completed notarized application, copy of ID, proof of residence if different from your photo
identification and check or money order for exact amount to: OVR, PO Box 1088, Austin TX 78767.)
PART 1. TYPE OF RECORD BEING ORDERED
Baby/Long Form Birth Certificate
$23.00 EACH
Available for Austin births only.
Total # of Copies: __________
Security Size Birth Certificate
$23.00 EACH
Available for most Texas births from 1926.
Total # of Copies: _________
Death Certificate
$21.00 + $4.00 copies
Available for Austin deaths only.
Total # of Copies: _________
PART 2. PERSON ON THE BIRTH OR DEATH RECORD
Name on Record: _______________________
___________________
_____________________________
FIRST
MIDDLE
LAST
Date of Birth:
Place of Birth:
______________________
_______________________ Gender _________
OR Death :
OR Death:
/
/
and
/
MONTH
DAY
YEAR
CITY
COUNTY
M
F
Parent #1: _______________________
___________________
____________________________________
(
)
FIRST
MIDDLE
LAST NAME
PRIOR TO MARRIAGE
Parent #2: _______________________
___________________
____________________________________
(
)
FIRST
MIDDLE
LAST NAME
PRIOR TO MARRIAGE
PART 3. PERSON APPLYING FOR RECORD
Your full
Your relationship to person
legal name: ____________________________________________
named on the record: ________________
Your current address: ______________________________________________ __________________________
S
,
,
TREET ADDRESS
CITY
STATE
ZIP
Daytime phone number: ______________________________
Email: ___________________________________
Reason for your purchase of the record: ____________________________________________________________
Signature: __________________________________________
Date signed: ____________________________
PART 4. COMPLETED BY NOTARY PUBLIC
STATE OF ____________, COUNTY OF ___________ Before me on this date appeared the above named applicant
in Part 3 who on oath deposes and says the contents of this document are true and correct. The applicant presented
the following type and number of identification: _______________________________________________________
Sworn to and subscribed before me, this __________ day of ____________________, 20________.
Signature of Notary Public and Notary ID Number: __________________________________________________________________________
Typed or Printed Name: _______________________________________
(SEAL)
Commission Expires: _________________________________________
Street Address: ______________________________________________
City, State, Zip: ______________________________________________
- - - - - - FOR OFFICE USE ONLY - - - - - - -
Paper #(s)
________________________________________________
Payment: __________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Nih 2762-3 - Undergraduate Scholarship Program (ugsp) - Academic Enrollment Certification And Service Obligation Deferment Request - U.s. Department Of Health And Human Services
Legal
Form Dhhs-2887 - Public Water Supply Regional Office Request - N.c. Department Of Health And Human Services
Legal
Form Dhcs 0004 - California Request For California Birth Record - Health And Human Services Agency
Legal
Medication Management Services Only - Continued Stay Review Form - Maine Department Of Health And Human Services
Legal
Montana State Case Registry And Vital Statistics Reporting Form Department Of Public Health And Human Services
Legal
Related Categories
Parent category: Business