Application For Birth Or Death Record - Carthage, Texas
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1
2
3Office Use Only
Office Use Only
Cert. #
Remit No.
Document Control #
By
By
Application for Birth or Death Record
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID WHEN SENDING THE REQUEST.
Birth Certificates
Death Certificates
Type
Cost X
# of Copies
Total
Type
Cost X
# of Copies
Total
Certified Copy
$23
$
Certified Copy (1 copy)
$21
$
Protective Cover
Additional Copies
$ 4
$ 4
$
Short Form
$ 3
$
Long Form
Protective Cover
$ 3
Total
$
Total
$
1. Full Name of
First Name
Middle Name
Last Name
Person on Record
2. Date of Birth or
Month
Day
Year
3. Sex
Male
Female
Death
4. Place of Birth or
City or Town
County
State
Death
5. Full Name of
First Name
Middle Name
Last Name
Father
6. Full Name of
First Name
Middle Name
Maiden Name
Mother
7. Your 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 this 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 _________________ Birthplace ________________________________
I authorize mailing to the address below instead of my mailing address. I have verified that the address below will receive my order.
Name _____________________________________ Street Address ____________________________________________________
City _______________________________________ State _________________________ Zip ___________
For any search of the files where a record is not found, the searching fee is not refundable or transferable.
Your Signature ___________________________________________________________ Date of Application ___________________
Mail this application, payment (made payable to City of Carthage) and a photocopy of your valid photo id to:
City of Carthage
Dana Clark, Local Registrar
P.O. Box 400
Carthage, TX 75633
APPLICATIONS WITHOUT PHOTO ID WILL NOT BE PROCESSED.
Warning: The penalty for knowingly making a false statement on this form is 2-10 years imprisonment and a fine of up to $10,000.
(Health and Safety Code, Chapter 195, Sec. 195.003)
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