Application For Certified Copies - Warren City Health District Page 2
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2Warren City Health District
APPLICATION FOR CERTIFIED COPIES
RECORD INFORMATION:
(Information about the person you are requesting the record for)
If name was changed since birth, indicate new name:
Full name on birth or death certificate:
(i.e. adoption, legal name change, paternity, etc.)
First
Middle
Maiden/Last
Date of Birth:
and/or
Date of Death:
City and County where event occurred:
□ Mother
Full First
Full Middle
Maiden or Last Name
□ Mother
Full First
Full Middle
Maiden or Last Name
□ Father
□ Father
□ Parent
□ Parent
CHARGES:
Accepted Types of Payment: Cash or Money Order
If you do not need a birth certificate for any of the following reasons, skip
Number of copies requested:
Birth:
this section. Otherwise please indicate what the certificate is needed for:
□ Dual Citizenship
□ Genealogy
□ International Legal Business
□ Out of Country Marriage
______ x $23.00 = $__________
All death certificates will be issued without a social security number
unless identification is provided confirming you are one of the below
listed authorized requestors:
Number of copies requested:
□ The deceased’s spouse or descendent
□ The deceased’s executor, attorney, or legal agent
______ x $23.00 = $__________
□ A representative of investigative government agency
Death:
□ A private investigator
□ A funeral director (or agent responsible for disposition of the body) acting on
Burial Permits:
behalf of the deceased’s family
□ A veteran’s service office
______ x $3.00 = $__________
□ An accredited member of the media
You must attach a copy of your identification showing you are an
authorized requestor along with a copy of a valid driver’s license.
Number of fetal death record
copies requested:
Fetal Death:
______ x $23.00 = $___________
Total Amount Due:
$_______________
PURCHASER’S INFORMATION:
(Information about the person requesting the record)
Please print clearly as this will be used for your receipt, mailing address, and/or for future contact to complete your record request.
Purchaser’s
Email:
Name:
Street Address:
Phone Number:
Purchaser’s
City, State, & ZIP:
Signature:
MAILING ADDRESS
FOR OFFICE USE ONLY:
Send completed application with required fee to:
Receipt Number:
Date:
Warren City Health District
Security Paper Number:
Clerk:
258 East Market Street
Warren, OH 44481
(Rev: 8/2016)
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