APPLICATION FOR

VITAL STATISTICS RECORD
 

Important:                                  
Completion of this form is not mandatory.  Your refusal to complete or provide any and/or all information on this form will not affect your right and/or ability to inspect and/or receive  copies or reproductions of the requested records (R. C. 149.43 (B)(5)). If you complete this form it will help us to better and more effectively serve you in providing you with the records you are requesting.

1.  General Information: (please print)

 

Today's Date

 

 

 

Telephone Number

 

 

 

Name

 

 

 

Street Address

 

           

 

City

 

 

 

State

 

 

 

Zip

 

 

2. Requested Record (please print)
  

    Information as it appears on the certificate being requested

 

First Name

 

 

 

Middle Name

 

 

 

Last Name

 

 

 

Date of Birth/Death

 

 

 

Father's Full Name

 

 

 

Mother's Maiden Name

 

 

3. Copies

 

Number of Copies Requested

 

 # Copies = ________ x $16.50 = ______

 

Select One

 

Mail               Pick up            Online

 

 

  □                □               □

 

FOR OFFICE USE ONLY

 

Date Request Received

 

Date Request Processed

 

# copies issued

 

Audit #

 

 

 

 

 

 

 

 

 

Prepared By:

 

Certificate not issued Reason

 

 

 

 

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This page updated: Monday October 29, 2007 03:22 PM
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