Application For Certified Copy Of Birth Or Death Record - County Of Stanislaus Page 2

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County of Stanislaus

Office of the Clerk-Recorder

APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH RECORD

NOTICE: Orders sent by mail or messenger must include the accompanying Certificate of Identity Statement,

sworn under penalty of perjury and executed before a Notary Public (see accompanying instructions).

California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified copies of

birth or death records. Those who are not authorized by law to receive an Authorized Certified Copy will receive a certified copy

marked "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY." Please indicate whether you would

like an Authorized Certified Copy or a certified Informational Copy.

I would like an Authorized Certified Copy of the record

I would like a certified Informational Copy of

identified on the application form. (In order to receive an

the record identified on the application form.

Authorized Certified Copy, you must indicate your relationship to

(You are not required to select from the list below

nor required to complete the back side of this form in

the person named on the application form by selecting from the

order to receive an Informational Copy.)

list below; AND complete the Certificate on the BACK SIDE.)

I am:

The registrant (person named on the certificate) or a parent or legal guardian of the registrant.

A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the birth

record in order to comply with the requirements of Section 3140 or 7603 of the Family Code.

A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is

conducting official business.

A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant (person named on the certificate).

An attorney representing the registrant (person named on the certificate) or the registrant's estate, or any person or agency

empowered by statute or appointed by court to act on behalf of the registrant or the registrant's estate.

An agent/employee of a funeral establishment, acting within the scope of employment, who is ordering certified copies of a

death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section 7100 of the

Health and Safety Code.

Attention: Read accompanying instructions before completing this form.

APPLICANT INFORMATION (PLEASE PRINT OR TYPE)

Printed Name and Signature of Person Completing Application

Today’s Date # Copies

Telephone Number – Area Code First

(

)

Address – Number, Street

City

State

ZIP Code

Name/Address of Person Receiving Copies, If Different From Above

City

State

ZIP Code

REGISTRANT INFORMATION (PLEASE PRINT OR TYPE)

Name on Certificate – First

Middle

Last

Sex

Date of Birth

Place of Birth – City or Town, State

BIRTH CERT

Father's First and Last Name

Mother's First and Maiden Name

Date of Death (Or period of years to search)

Place of Death – City or Town, State

DEATH CERT

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Type of Certificate

Checked By

Filled By

Delivered By

Date Delivered

Type Issued

Birth

Death

Certified

Informational

Certificate #

Bond Paper #