Form Vs-142.3 - Expedited Mail Application For Birth And Death Record - 2015 Page 3
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3NOTARIZED PROOF OF IDENTIFICATION
ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON
PART I.
BIRTH/DEATH &(57,),&$7(
DATE OF BIRTH/DEATH
FULL NAME OF PERSON ON RECORD
PLACE OF BIRTH/DEATH (City or County)
SEX
FULL NAME OF PARENT 1
FULL NAME OF PARENT 2
PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.
TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
NAME AND RELATIONSHIP TO PERSON ON RECORD
AFFIDAVIT OF PERSONAL KNOWLEDGE
PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.
STATE OF
_____________________
COUNTY OF _____________________
Before me on this day appeared ____________________________BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB___________BB
(Name)
QRZUHVLGLQJDWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB__________________BB
(Address)
(City)
(State)
who is related WRWKHSHUVRQQDPHGRQ3DUW,DVBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB___BBDQGZKRRQRDWKGHSRVHVDQG
(Relationship)
VDVWKDWthe contents of this affidavit are true and correct.
Signature ____________________________________________________________
Sworn to and subscribed before me, this ________ day of ______________________, 20 ______.
Signature of Notary Public
Commission Expires
(Seal)
Typed or Printed Name
Street Address
City, State and Zip
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND
A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Texas Vital Records
Department of State Health Services
P.O. Box 12040
Austin, TX 78711-2040
(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
Page 2 of 2
VS-142.3(A) Rev. 09/2015
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