Application For Certified Copy Of Birth Record - Mendocino County
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3Mendocino County
Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
NOTICE:
Orders received by mail must be accompanied by the attached sworn statement (see the instructions on
the back of this form).
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified
copies of birth records. Those who are not authorized by law to receive a certified copy will receive a certified copy marked
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like a
Certified Copy or a certified Informational Copy.
______________________________________________________________________________________________________
□
□
I would like a Certified Copy of the record identified on the
I would like a certified Informational Copy of
application form
the record identified on the application form
. (In order to receive a Certified Copy, you
.
must indicate your relationship to the person named on the
(You are not required to select from the list below
application form by selecting from the list below.)
in order to receive an Informational Copy.)
____________________________________________________________________________________________________
I am:
□
The registrant 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.
□
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the registrant or the registrant’s estate.
STOP!
DO NOT complete the rest of this form before reading the detailed instructions on the back.
(PLEASE PRINT OR TYPE)
APPLICANT INFORMATION
Printed Name and Signature of Person Requesting Record
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
E-mail Address
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
(PLEASE PRINT OR TYPE)
BIRTH CERTIFICATE INFORMATION
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
City or Town of Birth
Place of Birth – County
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Name on Certificate – Father ‘s First Name
Name on Certificate – Father’s Middle Name
Name on Certificate – Father’s Last Name
Name on Certificate – Mother’s First Name
Name on Certificate – Mother’s Middle Name
Name on Certificate – Mother’s Last Name
BIRTH
VS 111 (7/03)
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