Form Adph-Hs-14h - Alabama Request For Keepsake Birth Certificate
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1
2ALABAMA
REQUEST FOR KEEPSAKE BIRTH CERTIFICATE
The Center for Health Statistics may issue a Keepsake Birth Certificate for anyone born in Alabama for whom there is a record
on file in our office. Even though the Center began collecting birth certificates in 1908, most Keepsake Birth Certificates are
requested for younger children, especially since the Keepsake Birth Certificate is not a record that can be used for legal
purposes.
By Alabama law, birth certificates are confidential records with restricted access for 125 years from the date of birth. They may
be obtained by the following persons, upon payment of the proper fee:
Person Named on the Certificate, Mother/Father of Person Named on Certificate
Husband/Wife of Person Named on Certificate, Son/Daughter of Person Named on Certificate
Sister/Brother of Person Named on Certificate
If you are not one of the authorized individuals above, such as a grandparent, one of the above individuals MUST give you
written and signed permission to obtain a Keepsake Birth Certificate. The permission MUST accompany this request form and
the required fee.
The fee to search for and provide one copy of a Keepsake Birth Certificate is $45.00. Make check or money order payable to
“State Board of Health.” F
-
. If the record is not located, you will receive a Certificate of Failure to Find
EES ARE NON
REFUNDABLE
but will still be responsible for the $15.00 fee to search for the record. Each Keepsake Birth Certificate requested is $45.00 even
if it is for the same child.
YOU MUST PROVIDE ALL INFORMATION BELOW AND SIGN THE APPLICANT SECTION OR YOUR REQUEST CANNOT
BE PROCESSED. DO NOT USE THIS FORM to order legal certified copies of birth certificates.
For additional information/questions call 334.206.5418 or visit our website at:
MAIL COMPLETED FORM AND FEE TO:
ALABAMA CENTER FOR HEALTH STATISTICS
P.O. BOX 5625
MONTGOMERY, ALABAMA 36103-5625
BIRTH:
Number of Copies Requested
_______
Amount Enclosed $
____________
Please indicate the design you would like:
_____Kites _____ Bunnies _____Nature
FULL NAME AS ON
BIRTH CERTIFICATE_______________________________________________________________________________________________________________________________
FIRST
MIDDLE
LAST
DATE OF BIRTH __________________________________________________________________________SEX_____________________________________________________
COUNTY OF BIRTH _______________________________________________________________ HOSPITAL________________________________________________________
FULL MAIDEN NAME
OF MOTHER______________________________________________________________________________________________________________________________________
FIRST
MIDDLE
LAST
FULL NAME OF
FATHER__________________________________________________________________________________________________________________________________________
FIRST
MIDDLE
LAST
APPLICANT SECTION (THIS SECTION MUST BE COMPLETED)
Anyone falsely applying for a record that is restricted by law is subject to a penalty upon conviction of up to three months in the
county jail or a fine of up to $500. Code of Ala. 1975, § 13A-10-109. By signing, you are certifying you have a legal right to the record
requested.
YOUR SIGNATURE _______________________________________________________________DATE __________________________________________
PRINT YOUR NAME ________________________________________________ DAY TIME PHONE (
)________________________________
ADDRESS
___
_
CITY
STATE
__
ZIP _________________________
Your Relationship to Person Whose Record is Being Requested ________________________________________________________________________________
I allow the following individual to order the Keepsake Birth certificate(s): _______________________________________________________________________
ADPH-HS-14H/12-15-2009
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