Application For Certified Copy Of Birth Or Death Certificate

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______________________________________________________________________________________________

STACEY KEMP, COUNTY CLERK

Application for Certified Copy of Birth or Death Certificate

DEATH - NUMBER REQUESTED

BIRTH - $23.00 Each

____$21.00 1

Certified Copy

NUMBER REQUESTED _____

____$ 4.00 each additional copy ordered at this time

Full name on record: ______________________________________________________________________________

First

Middle

Last

Date of Birth or Death: ____________________________ County of Birth or Death: ___________________________

Father/Parent 1: __________________________________________________________________________________

First

Middle

Last

Mother/Parent 2: _________________________________________________________________________________

First

Middle

Last (Maiden)

Applicant’s Name: ________________________________________________________________________________

Daytime Phone Number: ____________________________ Email Address: ________________________________

Applicant’s Mailing Address: ________________________________________________________________________

Street

City

State

Zip

Relationship to person named on certificate: ___________________________________________________________

Purpose for obtaining copy of certificate: Please check all that apply.

____Driver License

____Housing

____Insurance

____Passport

____Records

____School

____Social Security

____Travel

____Veterans

____Welfare

Other, please specify:____________________________________________________________________________

NOTICE: Providing false information on this application is a violation of the law and may lead to fine or imprisonment, or both. The person to whom any certified copy of Birth or Death Record is

issued must be a properly qualified applicant. The applicant must have a direct and tangible interest in the record and further, should have a significant legal relationship to the person whose record is

requested. The purpose for which the certified copy is needed and the relationship of the applicant to the registrant is essential to determination as to whether or not the person making the request is a

properly qualified applicant. (Health and Safety Code, Chapter 678, Sec. 196.003)

Witness my/our hand(s) this_____________________day of _________________________________, 20_____.

Signature of Applicant_____________________________________________________________

THE STATE OF ________________________ }

COUNTY OF __________________________ }

BEFORE ME, ______________________________________________,

(SEAL)

in and for said County and State, on this day personally appeared

__________________________________________________________,

known to me to be the person(s) whose name subscribed to the foregoing

instrument, and acknowledged to me that he/she/they executed the same

for the purpose therein expressed.