Application For Certified Copy Of Birth Or Death Record
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1
2Vital Records Office
Tel: 408-885-2010
Tel: 408-885-2010
976 Lenzen Ave suite 1300
976 Lenzen Ave suite 1300
Web:
Web:
San Jose, CA 95126
Office Hours: M-F 9am – 4pm
(IN-PERSON) APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH RECORD
See Instructions on Page 2
SECTION A
Indicate the quantity of each item you would like to purchase, total enclosed, and method of payment.
ITEM
QTY
PRICE
TOTAL
METHOD OF PAYMENT
Birth Certificate
x $19.00
= $
Cash
Death Certificate
x $12.00
= $
Check #_________
Stillbirth Certificate
x $9.00
= $
Money Order
Fetal Death Certificate
x $9.00
= $
TOTAL ENCLOSED
$
SECTION B
Indicate the type of certified copy you are requesting.
Unrestricted Certified Copy of the record identified on the
Informational Certified Copy of the record identified on the
application form. Identification is required.
application form. Skip to Section C.
For an Unrestricted Certified Copy, I am:
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 requirements of the Family Code. A certified copy of documentation is required.
Any law enforcement or state or local government representative, 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. A certified copy of documentation is required.
Any agent or employee of a funeral establishment ordering certified copies of a death certificate on behalf of their client.
SECTION C
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Telephone Number with Area Code, in
Organization Name
case clarification is needed.
First & Last Name
Today’s Date
Address – Number,
Street
City, State & ZIP Code
CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
First (Given) Name of Child or Decedent
Middle Name
Last (Family) Name
Sex
Place of Birth (Name of Hospital or Home) OR
City of Death
County of Birth or Death
Date of Birth or Death MO-DY-YR
Mother’s Maiden Name
Name of Father/Parent-First
OFFICE USE ONLY
Local File Number
ID Type
ID #
Staff Initial
Date Run
REV1/2011
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