Person On The Birth Or Death Record, Person Applying For Record, Notarized Proof Of Identification6 Affidavit Of Personal Knowledge
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1
2- - - - - - - FOR OFFICE USE ONLY - - - - - - -
Office of Vital Records
Austin/Travis Co. Health and Human Services Dept.
7201 Levander Loop, Bldg. C, Austin, TX 78702
Doc# _________________
PAGE
PO Box 1088, Austin, TX 78767-1088
1 OF 2
Phone (512) 972-4784 / Fax (512) 972-5208
State# ________________
Certified vital records can be
BIRTH RECORDS $23.00 Each
DEATH RECORDS
issued to the registrant or a member
(Available for Austin deaths only.)
SECURITY SIZE
of the immediate family (parents,
LONG/
grandparents, legal guardian, spous-
(Recommended for
BABY FORM
First Copy $21.00
es, siblings or children of the regis-
daily use. Available for
(Available for Austin
trant), or to other persons with a
most Texas births from
Each Additional Copy $4.00
births only.)
legal and tangible interest in the
1926 to present.)
record (must be established by
Total #
Total #
providing sufficient documentation
Total # of Copies: _________
of Copies: _________
of Copies: _________
to establish the need).
PERSON ON THE BIRTH OR DEATH RECORD
Name on Record: _______________________ ___________________ ____________________ _________
FIRST
MIDDLE
LAST
SUFFIX
Date of Birth:
Place of Birth:
______________________
_______________________ Gender _________
OR Death :
OR Death:
/
/
and
/
MONTH
DAY
YEAR
CITY
COUNTY
M
F
Father’s name: ________________________ ____________________ ___________________
_________
FIRST
MIDDLE
LAST
SUFFIX
Mother’s name: ________________________ ____________________ ______________________________
(
)
FIRST
MIDDLE
LAST
MAIDEN
PERSON APPLYING FOR RECORD
Your full
Your relationship to person
legal name: ____________________________________________
named on the record: ________________
Your current address: ______________________________________________ __________________________
S
,
,
TREET ADDRESS
CITY
STATE
ZIP
Daytime phone number: ______________________________
Email: ___________________________________
Reason for the purchase
MAIL REQUESTS MUST INCLUDE:
of the record: _____________________________________
* COPY OF CURRENT GOVERNMENT-
ISSUED IDENTIFICATION
Your signature: ______________________________________
* NOTARIZED STATEMENT (SEE PAGE 2)
* PROOF OF RESIDENCE
Today’s date: ________________________________________
THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM CAN BE 2 TO 10 YEARS
IN PRISON AND A FINE OF UP TO $10,000 (Health and Safety Code, Chapter 195, Sec 195.003)
Paper #(s) __________________________________________
Payment Information:
__________________________________________
___________________________
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