Application For Birth Or Death Record City Of Nederland
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1
2CITY OF NEDERLAND VITAL STATISTICS
P O BOX 967
NEDERLAND, TEXA 77627
S
409.723.1505
APPLICATION FOR
BIRTH OR DEATH RECORD
BIRTH
DEATH
#REQUESTED
#REQUESTED
CERTIFIED COPIES X $22.00 =
CERTIFIED COPIES X $20.00 =
EXTRA COPIES X $3.00 =
=
TOTAL ENCLOSED
TOTAL ENCLOSED
=
PLEASE PRINT
See Reverse Side for Instructions
1. Full Name of
First Name
Middle Name
Last Name
Person on
Record
2. Date of
Month
Day
Year
3. Sex
Birth or Death
4. Place of
City or Town
County
State
Birth or Death
5. Full Name
First Name
Middle Name
Last Name
of Father
6. Full Maiden
First Name
Middle Name
Maiden Name
Name of Mother
7.
APPLICANT'S NAME:
8. TELEPHONE #: (
)
(MON-FRI 8:00-5:00)
EMAIL ADDRESS:
9.
MAILING ADDRESS:
STREET ADDRESS
CITY
STATE
ZIP
10. RELATIONSHIP TO PERSON NAMED IN ITEM 1:
11. PURPOSE FOR OBTAINING RECORD:
□
□
12. WILL THIS RECORD BE USED TO OBTAIN A PASSPORT, FOR IMMIGRATION OR FOR THE INDIAN REGISTRY?
YES
NO
13. ADDITIONAL INFORMATION FOR DEATH CERTIFICATE. BIRTHDATE
BIRTH PLACE
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE
OF UP TO $10,000 (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
SIGNATURE OF APPLICANT
DATE
MAIL THIS APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
CITY OF NEDERLAND
VITAL STATISTICS DEPARTMENT
P. O. BOX 967
NEDERLAND, TEXAS 77627
APPLICATIONS WITHOUT A PHOTO ID WILL NOT BE PROCESSED.
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