Division Of Vital Records - Pennsylvania Department Of Health
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1Penn sy lvania Depart ment of Health
Division of Vital Records
This form is to be used for corrections on a Certificate of Birth
Please complete the lower portion of this form in the presence of a
.
notarizing official and forward to: Division of Vital Records, PO Box 1528, New Castle, PA 16103.
Submit a photocopy of the documentary evidence used to support the correction requested, such as Baptismal Record, School
Record, Military Record, Marriage Record or Certified Court Order.
ORIGINAL RECORD NOW READS
CORRECTION DESIRED
Name of Subject
Date of Birth
Sex
Father
Mother
Other
MO.
DAY
YEAR
SUBSCRIBED AND
SWORN TO OR
AFFIRMED
BEFORE ME:
S
Father’s Signature
E
SIGNATURE OF PERSON ADMINISTERING OATH
Mother’s Signature
A
Subject’s Signature
L
DO NOT NOTARIZE UNLESS SIGNED BY
Present Address
SUBJECT
(OR PARENT(S) IF UNDER AGE 18)
MUST BE SIGNED IN PRESENCE OF NOTARY
Daytime Phone #
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