Application For Certified Copy Of Birth/death Certificate Form

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DEPARTMENT OF HEALTH AND HOSPITALS
OFFICE OF PUBLIC HEALTH
VITAL RECORDS REGISTRY
APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH CERTIFICATE
PHS 520A
(Rev. 3/98)
FOR SERVICE BY MAIL: SUBMIT CHECK OR MONEY ORDER PAYABLE TO VITAL RECORDS. MAIL TO:
VITAL RECORDS REGISTRY, P.O. BOX 60630, NEW ORLEANS, LA 70160. PLEASE DO NOT SEND CASH.
IF NO RECORD IS FOUND, YOU WILL BE NOTIFIED AND FEES WILL BE RETAINED FOR THE SEARCH.
BIRTHCARD:
$ 9.00
BIRTHCARD
BIRTH CERTIFICATE:
$15.00
BIRTH CERTIFICATE
DEATH CERTIFICATE:
$ 5.00
DEATH CERTIFICATE
*See Note Below:
______________________________________________________
NAME AT BIRTH/DEATH (FIRST, MIDDLE, LAST)
_______________
________________________________________________
DATE OF BIRTH/DEATH
SEX
______________________________
_____________________
CITY OF BIRTH/DEATH
PARISH OF BIRTH/DEATH
______________________________________________________
FATHER’S NAME (FOR BIRTH RECORD ONLY)
______________________________________________________
)
MOTHER’S MAIDEN NAME –BEFORE MARRIAGE (FOR BIRTH RECORD ONLY
HOW ARE YOU RELATED TO THE PERSON WHOSE RECORD YOU ARE REQUESTING?_____________
PRINT YOUR ADDRESS:
Name ________________________________________________________
Street or
Number of
Route No. _____________________________________________________
Copies Requested:
________________
City
And State______________________________________________________
Total Fees Due
$ _______________
ZIP CODE
Home
Office
Phone No.__________________________ Phone No.____________________
I AM AWARE THAT ANY PERSON WHO WILLFULLY AND KNOWINGLY MAKES ANY FALSE STATEMENT IN
AN APPLICATION FOR A CERTIFIED COPY OF A VITAL RECORD IS SUBJECT UPON CONVICTION TO A
FINE OF NOT MORE THAN $10,000 OR IMPRISONMENT OF NOT MORE THAN FIVE YEARS, OR BOTH.
Signature of Applicant _________________________________________________________
*PLEASE NOTE:
Birth records over 100 years old and Death records over 50 years old are obtained by writing the
Louisiana State Archives, P.O. Box 94125, Baton Rouge, La 70804-9125. Please make check
PAYABLE TO: Secretary of State.
_________________________________________________________________________________________________________
SEARCH METHOD EMPLOYEE
DATE
T RANSMITTAL:
____________
______
COMPUTER:
____________
______
MICROFILM:
____________
______
BOOK INDICES:
____________
______
CHARITY CARDS:
____________
______
CERTIFICATE TO BE MAILED TO:
DELAY CARDS:
____________
______
HAND SEARCHED;
____________
______
Name ___________________________________________________________
Street or
OTHER(INDICATE)
Route No. ________________________________________________________
City
And State ________________________________________________________
______________________________
______
______________________________
______
ZIP CODE
CERTIFICATE #
____________________

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