Application For Certified Copy Of Birth Record - Pennsylvania Department Of Health
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1H105.102 REV 12/03
BIRTH
BIRTH
Application for Certified Copy of Birth Record
Pennsylvania Department of Health Division of Vital Records
(Records available from 1906 to the present)
By my signature below, I state I am the person whom I represent myself to be herein, and I affirm the information within this form
is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. In
addition, I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or
felony criminal penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania Crimes Code.
Signature of person making request:______________________________________________________________________
Signature required on ALL requests. Must be 18 years of age or older to apply. If under 18, eligible requestor must sign above.
PRINT or TYPE your name &
CURRENT
address.
Relationship to Person
Name: ___________________________________________ Named on Certificate: ______________________________
Address: ____________________________________________________________________________________________
City: ___________________________________________________________ State: ________________ Zip: _________
Daytime phone number: (______) ________- _________
E-mail Address: ___________________________________
Intended Use of Certified Copy:
Travel (Date needed: _________________)
Social Security/Benefits
School
Employment
Driver’s License
Other (List reason: ________________________________________________)
PHOTO ID REQUIRED:
The individual requesting the record must send a legible copy of his/her
VALID
GOVERNMENT ISSUED PHOTO ID
with completed application. (Examples: State issued driver’s license or non-
driver photo ID with requestor’s
current address
or passport. If possible, enlarge photo ID on copier by at least 150%.)
PRINT or TYPE information below with regard to person named on requested certificate:
Number of copies: ______
__
Name at Birth: ________________________________________________________________________________
If name has changed since birth due to adoption, court order,
___________________________________________
or any reason
other than
marriage, please list changed name here
:
Date of Birth: __________________________
Age Now: _________
Sex:
Male
Female
(Month/Day/Year)
Place of Birth: _____________________________________________________ Hospital: ___________________
(County)
(City/Boro/Township in Pennsylvania)
Full Maiden Name of Mother: ____________________________________________________________________
Full Name of Father: ___________________________________________________________________________
BIRTH: $10.00 each
No fee may be required for birth records of active or inactive members of the Armed Forces and their dependents.
Please complete the following:
Armed Forces Member’s Name: ____________________________ Service Number: _________________________
Relationship to Armed Forces Member:______________ Rank and Branch of Service: ________________________
If fee is required, make check/ money order payable to: VITAL RECORDS. Complete this application and mail with
legible copy of ID to: Division of Vital Records, 101 South Mercer St., PO Box 1528, New Castle, PA 16101.
You are welcome to visit one of our public offices in the following cities:
♦ New Castle, PA, Room 401, 101 South Mercer St.
♦ Philadelphia, PA, Philadelphia State Office Bldg,
Room 1009, 1400 West Spring Garden St.
♦ Erie, PA, 1910 West 26
♦ Pittsburgh, PA, Pittsburgh State Office Bldg,
th
St.
Room 512, 300 Liberty Ave.
♦ Harrisburg, PA, Health and Welfare Bldg,
♦ Scranton, PA, Scranton State Office Bldg, Room 112,
th
Room 129, 7
and Forster Sts.
100 Lackawanna Ave.
For
ON-LINE ORDERING
or additional information, visit our website:
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