Form Ph-1654 - Application For Certified Copy Of Certificate Of Birth

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TENNESSEE DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS
APPLICATION FOR CERTIFIED COPY OF CERTIFICATE OF BIRTH
(La versión en español al reverso de la página)
Date:
Indicate number of each type
of certificate desired, and if
Full name on birth certificate:
applicable, the number of
First
Middle
Last Name
Voluntary
Acknowledgement
of
Paternity
and
enclose
Has the name ever been changed other than by marriage?
Yes
No
appropriate fees:
If yes, what was original name?
For years 1949-Current:
___ Short form- $15.00 Per
Copy
Male or Female
Date of birth:
Sex:
Month
Day
Year
___ Long form- $15.00 Per
Place of birth:
Copy
City
County
State
Hospital where birth occurred:
___ Voluntary
Acknowledgement of
Paternity- $5.00 Per
Full name of father:
Copy
Full maiden name of mother:
For births before 1949:
No short form available
Last name of mother at time of birth:
___ $15.00 Per Copy
Next older brother or sister:
Younger:
The above fees are charged
for the search of records and
Signature of person making request:
will not be refunded even if no
record is on file in this office.
Relationship:
A 3-year search is provided
for the initial fee.
Purpose of copy:
(
)
Telephone number where you may be reached for additional information:
IT IS UNLAWFUL TO WILLFULLY AND KNOWINGLY MAKE ANY FALSE STATEMENT ON THIS APPLICATION.
All items must be completed and appropriate fees attached to process this request. Do not send cash. Send check or money order
payable to: Tennessee Vital Records. In addition, unless this application is notarized, you must send a photocopy of a
government issued ID showing your signature. If you have not received a response within 45 days, please write or call Tennessee
Vital Records at (615) 741-1763.
PH-1654 (rev06/2015)
RDA 10113
FILL OUT BELOW/ DO NOT DETACH
PRINT name and address of person to whom the certified copy is to be mailed.
SEND TO:
Tennessee Vital Records
st
Andrew Johnson Tower, 1
Floor
Name
710 James Robertson Parkway
Nashville, TN 37243
Address or Route
City and State
Zip Code

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