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2. Certificate Type*
   -- Select One --BirthDeath

   What kind of certificate are you requesting?

4. First Name*

   What is the name of the person whose information you are requesting?

5. Middle Name(s)
6. Last Name*
10. For Birth Certificates
12. Birth Date
    Birth Date

    If requesting a birth certificate, please enter the date of birth.

13. Mother's Maiden Name

    Last, First, Middle

14. Fathers Name

    Last, First, Middle

18. For Death Certificates
20. Date of Death
    Date of Death

    If requesting a death certificate, please enter the date of death.

21. Include SSN

    1. Yes
    2. No

    If requesting a death certificate for a death that occurred within the last 5 years, do you need the SSN included on the certificate?

22. Authorized SSN Recipients

    1. Spouse
    2. Veteran's Service Officer
    3. Lineal Descendant (child, grandchild)
    4. Class A or B Licensed Private Investigator
    5. State of Federal Prosecutor (or agent)
    6. Executor of the Estate
    7. Licensed Funeral Director (or agent)
    8. Power of Attorney, Agent of the Estate, or otherwise authorized to act on behalf of the decedent
    9. Newspaper Employee or Press Associate Member

    To have the SSN included on a death certificate, please select one of the following and attach documentation.

26. Number of Certificates Requested
27. Cost

    Certificates are $25 each.  

29. First Name*
30. Last Name*
32. Address1*
34. Street Number*
35. Street Name*
36. Street Type
37. Apt #
39. City*
40. State*
41. Zip*
43. Phone number

    Please include a phone number where you can be reached if there is a question or problem with your request.

44. Email

    Please include your email address so we can contact you in the event there is a question about your request.

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field