Application For Certified Copy Of Birth Or Death Certificate (Page 2 of 2) in pdf

Application For Certified Copy Of Birth Or Death Certificate Page 2

NOTARIZED PROOF OF IDENTIFICATION

Part I. Enter Name, Date and Place Of Birth/Death, and Names of Parents as Information Appears on

Birth/Death Certificate

Full name of person on record:

Date of birth/death:

Place of birth/death: (City or County):

Sex:

Full name of parent 1:

Full name of parent 2:

Part II: Enter Relationship to Person on Record and the Type of ID Used

Name and Relationship to Person on Record

Type and Number of ID Accepted when Notarized

AFFIDAVIT OF PERSONAL KNOWLEDGE

Part III: This Section Must Be Signed in the Presence of a Notary Public

State of ______________________

County of ____________________

Before me on this day appeared_________________________________________________________________

(Name)

now residing at______________________________________________________________________________

(Address)

(City)

(State)

who is related to the person named on Part I as _____________________________ and who on oath deposes and

says that the contents of this affidavit are true and correct.

Signature_____________________________________________

Sworn to and subscribed before me, this ______ day of _____________________, 20_____.

_________________________________________________________

Signature of Notary Public

_________________________________________________________

Commission Expires

_________________________________________________________

Typed or Printed Name

_________________________________________________________

Street Address

_________________________________________________________

City, State and Zip

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 IS 2 TO 10 YEARS IMPRISONMENTAND A FINE OF UP TO $10,000. (HEALTH & SAFETY

CODE 195, SEC. 195.003)

MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT AND A PHOTOCOPY OF YOUR VALID ID TO:

Waco McLennan County Public Health District

Vital Statistics

225 West Waco Drive

Waco, TX 76707

APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE

PROCESSED.

Page 2 of 2

Application For Certified Copy Of Birth Or Death Certificate Page 2

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