Application For Certified Copy Of Birth Or Death Certificate
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1
2McLennan County Public Health District
Vital Statistics Division
225 West Waco Drive
Waco, TX 76707
(254) 750-5462
Email address: Registrar@WacoTX.gov
Fax Number: (254) 750-5455
TEXAS
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE-
ONLY
Lines Below
CERTIFIED
CERTIFIED
Office Use Only
□ BIRTH
□ DEATH
CERTIFICATE
CERTIFICATE
Available for Texas Births
Must have occurred inside Waco city limits
Certificate #_________________
Short Form $23.00 X _____ = $_____
Certified Copy x____ $21.00 = $_____
Paper #_____________________
Long Form $23.00 X _____= $_____
Extra Certified Copies x ___$ 4.00 = $____
Paper #_____________________
*Long form available for Waco births ONLY
Total Amount Due $__________
Receipt #___________________
Total Amount Due $__________
*MAIL Request $10.00 fee to Expedite
*MAIL Request $10.00 fee to Expedite
Issued by___________________
PLEASE PRINT
First Name
Middle Name
Last Name
1.
Name on Record
Month
Day
Year
2.
For Birth Record
Sex: □ Male
Date of Birth
□ Female
Month
Day
Year
3.
For Death Record
Date of Death
City of Town
County
4.
Place of Birth or
TEXAS only
State:
Death
First Name
Middle Name
Last Name
5.
Father
First Name
Middle Name
MAIDEN Name
6.
Mother
Applicant (YOUR NAME)
7.
: _____________________________ 8. Telephone (Daytime) #(
)__________________________
Mailing Address: ____________________________________________________________________________________
9.
STREET ADDRESS
CITY
STATE
ZIP
Email Address (for Mail-In, Email or Fax request) ___________
10.
____________@____________
Your
relationship to the person named in item #1 above: ______________________________
11.
Travel School ID Passport Insurance Job Genealogy
:
12. Purpose for obtaining this record
Other ______________
Check One
A Copy of your ID MUST be attached to Email, Fax or Mail-In Request
13.
.
For any search of the files where a record is not found the searching fee is
NON-REFUNDABLE or TRANSFERABLE
_______________________________________________________
______________________________________________
SIGNATURE OF APPLICANT
DATE
INDENTIFICATION TYPE___________________
_____________________________________
(Driver license, ID Card, etc.)
Birth records are confidential for 75 years and death records for 25 years; therefore, issuance is restricted. Administrative rules require that on
restricted records, all identifying information (items 1-8), relationship (item 11), and purpose (item 12) be provided in order to issue the record.
Fees are subject to change without notice.
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 CAN BE 2-10 YRS IN
PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC.195.003).
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