APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
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BIRTH ____ |
DEATH ____ |
NUMBER REQUESTED |
NUMBER REQUESTED |
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____ CERTIFIED COPIES X $24.00 = ______ |
____ CERTIFIED COPY X $21.00 = ______ |
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Payment by Cashiers Check or Money Order |
____ COPIES OF SAME DEATH RECORD X $4.00 = ______ |
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TOTAL ENCLOSED = $ _____ |
TOTAL ENCLOSED = $ _____ |
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PLEASE PRINT 1. FULL NAME OF
PERSON ON RECORD __________________________________________________________
First Name Middle Name Last Name
2. DATE OF
BIRTH OR DEATH ______________________________ 3. SEX ___________________
Month Day Year
4. PLACE OF
BIRTH OR DEATH ______________________________________________________________
City or Town County State
5. FULL NAME
OF FATHER ____________________________________________________________________
First Name Middle Name Last Name
6. FULL MAIDEN NAME
OF MOTHER ____________________________________________________________________
First Name Middle Name Last Name
7. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE.
SOCIAL SECURITY NUMBER OF DECEASED _________________________________________
BIRTH DATE _____________________ BIRTH PLACE ETC. __________________________
8. APPLICANT'S NAME: __________________________________________________________
9. TELEPHONE :________(________)_______________________________________________
(MON-FRI 8:00-5:00)
10. MAILING ADDRESS: __________________________________________________________
11. RELATIONSHIP TO PERSON NAMED IN ITEM 1: ___________________________________
12. PURPOSE FOR OBTAINING RECORD: _____________________________________________
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WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM CAN
BE 2-10 YEARS IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY
CODE, CHAPTER 195, SEC. 195.003) _____________________________________ _____________________________ SIGNATURE OF APPLICANT DATE |
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IDENTIFICATION TYPE __________________________ NUMBER ______________________ ATTACH PHOTOCOPY Driver's License, I.D. Card, etc. On Driver's License, etc.
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For any search of the files where a record is not found the searching fee is non-refundable or transferable. Birth records are confidential for 75 years and death records for 25 years; therefore, issuance is restricted. Please attach a photocopy of ID to application. Administrative rules require that on restricted records, all identifying information (items 1-6), relationship (item 11) and purpose be provided in order to issue the record. |
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CITY OF AMARILLO |
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