Mother'S Worksheet For Child'S Birth Certificate
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4Mother’s Worksheet for Child’s Birth Certificate
FOR HOSPITAL USE ONLY:
MOTHER MR# _____________________________
NEWBORN MR# ________________________________
MEDICAID # _______________________________
DELIVERING DR ________________________________
RM # ____________
The information you provide on this worksheet is used to create your child’s birth certificate. The birth certificate is a legal document
used to prove your child’s age, citizenship and parentage. Your child will use the birth certificate throughout his/her life. The State of
Texas safeguards against the unauthorized release of identifying information from birth certificates to protect the confidentiality of
parents and their child.
Please PRINT your responses carefully and accurately as errors are difficult and expensive to correct.
CHILD’S PLACE OF BIRTH
Name of Hospital or Location
Address
State
County
City
Zip Code
CHILD’S INFORMATION
Time of Birth
Date of Birth
Plurality (please circle one)
Am / Pm
Single / Twin / Triplets / Quadruplets / Quintuplets
Birth Order (please circle one)
Number of Infants Born Alive at this Birth? (please circle one)
First / Second / Third / Fourth / Fifth
One / Two / Three / Four / Five
MOTHER’S CURRENT LEGAL NAME
First Name
Middle Name
Last Name
Suffix
CHILD’S LEGAL NAME
First Name
Middle Name
Last Name
Suffix
MOTHER’S RESIDENCE ADDRESS
Residence Address
Apartment Number
State/Foreign Country
County
City/Town/Location
Zip Code / Extension
Inside City Limits?
□
□
Yes
No
MOTHER’S MAILING ADDRESS (If same as residence address, LEAVE THIS SECTION BLANK)
Mailing Address
Apartment Number
State/Foreign Country
City/Town/Location
Zip Code / Extension
Inside City Limits?
□
□
Yes
No
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