Application For Birth Record And Notarized Certificate (Page 3 of 3) in pdf

CERTIFICATE OF IDENTITY/SWORN STATEMENT

FOR BIRTH, DEATH & PUBLIC MARRIAGE

In accordance with California State Law, the following identifying information is required to obtain a certified copy of a Birth,

Death or Public Marriage Certificate. You must be one of the following to receive an authorized copy of a birth, death or public

marriage record: Individual named on certificate, Parent, Child, Legal guardian/custodian, Grandparent, Grandchild, Sibling,

Spouse/Domestic partner, Attorney for individual/estate of individual or Representative of an adoption agency (birth only),

Funeral director or agent/employee (death only).

This certificate must be signed in the presence of a Notary.

Name(s) on Certificate

Relationship

I,_______________________________________________, declare under penalty of perjury under the laws of the State of

(Print Name)

California, that I am an authorized person, as defined in California Health and Safety Code Section 103526(c), and am eligible

to receive a certified copy of the birth, death or public marriage record for the individual(s) listed above.

Subscribed to the ______ day of __________________ 20_____, at ____________________________, ______________.

(Day)

(Month)

(Year)

(City)

(State)

(Signature)

A notary public or other officer completing this certificate verifies only the identity of the individual who signed

the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

CERTIFICATE OF ACKNOWLEDGEMENT

STATE OF CALIFORNIA

)

) ss

County of ____________________________ )

On ___________________________, before me _____________________________________________ personally appeared

(Date)

(Insert name and title of officer here)

______________________________________, who proved to me on the basis of satisfactory evidence, to be the person

whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her

authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person

acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and

correct.

WITNESS my hand and official seal. (NOTARY SEAL)

___________________________________

NOTARY SIGNATURE

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R1995 Rev. 6/16

Application For Birth Record And Notarized Certificate Page 3