Mdh Minnesota Certificate Of Birth Application (Page 2 of 3) in pdf

Mdh Minnesota Certificate Of Birth Application Page 2

MINNESOTA CERTIFICATE OF BIRTH

APPLICATION

This application must be signed in front of a notary public.

If boxes are left blank the application may be returned.

PART I: Birth Record Information

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

SEX

CITY & COUNTY OF BIRTH

MOTHER’S FIRST NAME

MIDDLE NAME

MAIDEN NAME

FATHER’S FIRST NAME

MIDDLE NAME

LAST NAME

PART II: What is your relationship to the subject (tangible interest)?

You must check one category.

I am the subject

I am the child of the subject

I am the spouse of the subject

I am the parent listed on the record

I am the grandparent of the subject

I am the grandchild of the subject

I am the party responsible for filing the birth record (i.e. hospital, midwife, birth attendant)

I am the legal custodian, guardian or conservator of the subject (you must submit a certified

copy of a court order showing this relationship)

I am the health care agent of the subject (you must submit documentation showing this

relationship)

I am a personal representative and the certified copy is required for the administration of the

estate (please submit documentation showing this relationship)

I have documentation that the record is necessary for the determination or protection of personal

or property rights (you must submit documentation showing this relationship)

I represent an adoption agency and the record is needed to complete a confidential post-

adoption search (please submit a copy of your employee ID)

I am an attorney and I have attached proof of my licensure

I am presenting your office with a court order issued by a court of competent jurisdiction (this

must be a certified copy)

I represent a local, state or federal governmental agency and the record is necessary for the

governmental agency to perform its authorized duties (please submit a copy of your

employee ID)

I am a representative authorized by a person listed above (you must submit a notarized

statement from a person listed above)

PURPOSE FOR YOUR REQUEST

If you have questions, please contact us at 218-732-3552.

B102 REV 05/2010

Mdh Minnesota Certificate Of Birth Application Page 2

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