Form Dhec 0640 - Vital Records Birth/death Application
Download a blank fillable Form Dhec 0640 - Vital Records Birth/death Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dhec 0640 - Vital Records Birth/death Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Vital Records Birth/Death Application
A photocopy of a current government, school or employer photo identification of the
applicant must be submitted with all requests.
Applications without proper identification will be returned unprocessed.
Name of applicant:_____________________________________________________________ Day phone number:______________________
Address: _____________________________________________________________________________________________________________
City:______________________________________________ State:_______________________________ Zip code:_______________________
Note: Mail from Vital Records will not be forwarded by the USPS.
Address certificate to be mailed to if different than applicant’s address:
Name: _______________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
City: ___________________________________________________________ State: _________________________ Zip code: ______________
Your relationship to person named on the certificate. (Check one - will be used to determine entitlement)
____Self
____ Adult child
____ Family member (specify) ____________________________________________________
____Parent
____ Legal Guardian
____ Legal representative (for whom?)______________________________________________
For what purpose are you requesting this certificate? _______________________________________________________________________
By signing this application, I understand that making a false application for a vital record is a felony under state law.
Signature of applicant: __________________________________________________________________________________________________
BIRTH CERTIFICATES
Full name: ____________________________________________________________________________________________________________
First
Middle
Last
Suffix
Date of birth:_____________________Sex: ________City of birth:___________________________ County of birth: ________________________
Name of mother prior to any marriage:_______________________________________________________________________________________
First
Middle
Last
Name of father:_________________________________________________________________________________________________________
First
Middle
Last
Mother's state of birth: ________________________________________ Father's state of birth:________________________________________
Were parents married at time of birth: ___ Yes ___ No
Number of children born in SC to this mother?____________
Name at birth if ever changed for any reason other than marriage: ________________________________________________________________
Specify the number and type of certification(s) requested: (Long form recommended)
____ Birth long ($12) ____ Additional long ($3 each)
____ Birth short ($12) ____ Additional short ($3 each)
Total fees submitted:__________________
DEATH CERTIFICATES
Name of deceased: _____________________________________________________________________________________________________
First
Middle
Last
Suffix
Date of death: _____________________ Sex:_______ Age at death:_______ City/County of death:__________________________________
Specify the number and type of certification(s) requested:
____ Death long ($12) ____ Additional long ($3 each)
____ Death short ($12) ____ Additional short ($3 each)
____ Death statement ($12) ____ Additional statement ($3 each)
Total fees submitted:_____________________________________
Send completed application/photocopy of identification to:
SC DHEC – Vital Records
2600 Bull Street, Columbia, SC 29201
OFFICE USE ONLY
SFN:
DCN:
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 0640 (09/2013)
See back for Instructions and Information
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business