Birth Or Death Certificate Application Form
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1
2OFFICE OF
PLACER COUNTY CLERK – RECORDER –
REGISTRAR OF VOTERS
Clerk - Recorder Office
2954 Richardson Drive ۰ Auburn, CA 95603
۰
(530) 886-5610 ۰ FAX (530) 886-5687
Ryan Ronco
County Clerk-Recorder-Registrar
APPLICATION FOR BIRTH or DEATH CERTIFICATE
California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive Authorized
Certified Copies of Birth or Death records. Those who are not authorized by law to receive an Authorized Certified Copy will
receive an Informational Certified Copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”
Please indicate whether you would like an Authorized or Informational Certified Copy.
Informational Certified Copy:
Complete Section I
Authorized Certified Copy:
Complete Sections I and II (Mail orders MUST be notarized - see back of form)
Section I: Complete for both Informational or Authorized Certified Copy (please print)
BIRTH CERTIFICATE
DEATH CERTIFICATE
Name on Certificate: (Last, First, Middle)
Name on Certificate: (Last, First, Middle)
Date of Birth:
Date of Death:
Number of Copies:
Total
Number of Copies:
Total
$0.00
Death
x $21.00 =
$0.00
$0.00
x $28.00 =
Fetal Death
x $18.00 =
*If a search results in no record found, the customer will be charged the cost of the record and a Certificate of No Record will be issued.
(Pursuant to Government Code § 27369 and Health & Safety Code § 103650).
Name of Applicant:
Today's Date:
Telephone Number:
(
)
Mailing Address:
City:
State:
Zip:
Signature of Applicant:
Section II: Complete for Authorized Certified Copy
Relationship of Applicant to Registrant:
Registrant (Name on Certificate)
Law Enforcement/Government Agency
Parent/Legal Guardian
Attorney of Record
Child
Funeral Director
Grandparent/Grandchild
Authorized by way of Court Order
Sibling
Licensed Adoption Agency
Spouse/Domestic Partner
I, _______________________________________, swear (or affirm) under penalty of perjury under the laws of 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 vital record identified on this application form.
Sworn on this date ____________________________, 20_______, in ___________________________________________.
(City, State)
Signature _________________________________________________________________________________________.
Office Use:
Receipt # _________________________
DL#________________________________________________
Date ___________________________
Bk/Page
Bank Note #
Deputy
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