Form Vs-142.3(A) - Application For Birth Or Death Certificate
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1
2P. O. Box 1151
Carolyn L. Guidry
Phone: 409.835.8475 Option 1
Beaumont, TX 77704‐1151
Jefferson County Clerk
Fax : 409.839.2394
APPLICATION FOR BIRTH OR DEATH CERTIFICATE
Birth Certificate
Death Certificate
____ No. of Certified Copies Requested
____ No. of Certified Copies Requested
@$23.00 each = __________________
@$21.00 for First Copy and $4.00 additional
copies of same record/same request
□
Applicant wishes to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visiting Program
administered by the Office of Early Childhood Coordination of the Health & Human Services Commission.
First Name
Middle Name
Last name
1. Full Name of Person on
Record:
2. Date of Birth or Death:
MM/DD/YYYY
3. Sex:
Male or Female
4. Place of Birth or Death:
City or Town
County
State
First Name
Middle Name
Last Name
5. Full Name of Father:
First Name
Middle Name
Last Name (Maiden)
6. Full Maiden Name of
Mother:
First Name
Middle name
Last Name
7. Applicant’s Name
(Give YOUR Full Name):
Home phone
Cell phone
8. Applicant’s Telephone
Number:
Street Address
City
State
Zip code
9. Mailing Address:
10. Relationship to Person
Named in Item No. 1:
11. Purpose for Obtaining
this Record:
12. Additional Identifying
Decedent’s SSN
Decedent’s Birth Date
Decedent’s Birth Place
Information for Death
Certificate:
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2‐10 YEARS
IN PRISON AND A FINE OF UP TO $10,000 (HEALTH & SAFETY CODE, CHAPTER 195, SEC. 195.003)
__________________________________
______________________________________________
Date of Application
Applicant’s Signature
If requesting by mail or Fax, Applicant must attach copy of Driver’s License or State Issued Identification.
Office Use Only
Certificate No. :__________________
Document Control No.: ___________________________
Form of I.D. :____________________
Number on D.L. or I.D.: ___________________________
Effective Date of Form: January 1, 2014
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