Application For Certified Copy Of Birth Or Death Record (Page 2 of 2) in pdf

SECTION D

Only to be completed by authorized persons requesting a Certified Copy of a birth or death record.

Not required for Fetal Death Certificates or Stillbirth Certificates.

SWORN STATEMENT

I, ____________________________________, declare under penalty of perjury under the laws of the State of California, that I am an authorized person, as

(Applicant’s Printed Name)

defined in California Health and Safety Code Section 103526 (c), and am eligible to receive an unrestricted certified copy of the birth or death record of the

following individual:

Name of Person Listed on Certificate

My Relationship to Person Listed on Certificate

Subscribed to this _______ day of ______________, 2011, at

__San Jose

_, CA

(Day)

(Month)

(City)

(State)

______________________________________________________

(Applicant’s Signature)

STOP! Sign only in the presence of Vital Records staff

IN-PERSON INSTRUCTIONS

INFORMATION: Copies of birth and death certificates are kept at the Santa Clara County Public Health Department for the current year

and one previous year. After this time, copies may be obtained from the Santa Clara County Clerk-Recorder's Office, 70

West Hedding Street, San Jose, CA, 95110, for the same fee(s).

SECTION A:

Indicate the quantity of each item you would like to purchase, total enclosed, and method of payment. Forms of

acceptable payment are cash, personal check, postal or bank money order, made payable to Vital Records Office.

Confidential Information: There is a bottom portion of the birth and fetal death certificate (entitled "Confidential

Information for Public Health Use") which contains confidential personal information (race, occupation, and medical data

- including pregnancy history). It can be included on an authorized copy only when specifically requested by the parent

as listed on the certificate. Because the confidential portion contains very personal information, it is not commonly used

(or needed) for identification, travel, school, or sports-related purposes. If requesting a birth or fetal death certificate that

contains the confidential portion, write “With Confidential Info” on the bottom of the application.

SECTION B:

Indicate the type of certified copy you are requesting, Unrestricted Certified Copy or Informational Certified Copy.

Both documents are certified copies of the original document on file with our office and contain the same information. An

Unrestricted Certified Copy is used to establish the identity of a registrant and can be issued only to authorized

individuals, as listed on Page 1, Section B. All others will be issued an Informational Certified Copy that is not valid to

establish identity. If you would like an Unrestricted Certified Copy, you must indicate your relationship to the registrant.

Identification is required. For court orders, powers of attorney, or other legal documents assigning representation rights, a

certified copy of the documentation is required. If you would like an Informational Copy, skip to Section C.

SECTION C:

Complete the Applicant Information section including Organization Name (if applicable), First and Last Name of Person

Completing the Application, Address, Telephone Number, and Today’s Date.

Complete the Certificate Information section with as much information as possible to identify the record. NOTE: if the

information you furnish is incomplete or inaccurate, it may be impossible to locate the record. If no record of the birth or

death is found, the fee(s) paid will be retained for searching as required by statute and a Certificate of No Public Record

will be issued.

SECTION D:

If you are requesting an Unrestricted Certified Copy, you must swear under penalty of perjury that you are an authorized

person to receive such a copy. Complete the Sworn Statement and sign only in the presence of Vital Records staff.

REV1/2011

Page 2 of 2

Application For Certified Copy Of Birth Or Death Record Page 2

Related Articles

Related forms

Related Categories