Application For Certified Copy Of Birth Or Death Certificate - Beaumont Public Health Department
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1
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3BEAUMONT PUBLIC HEALTH DEPARTMENT
VITAL STATISTICS DIVISION
P.O. BOX 3827
BEAUMONT, TX 77704-3827
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE – MAIL ONLY
Money Orders or Local Checks ONLY for Certificates
BIRTH ( )
DEATH ( )
# REQUESTED
# REQUESTED
______ CERTIFIED COPIES (BIRTH) = $23.00 each
______ 1
st
CERTIFIED COPY (DEATH) = $21.00 each
______ ADDITIONAL COPIES (DEATH) = $4.00 each
____ $11.00 Search Fee Only (No Record)
1.
Full name on record: _________________________________________________________________________
2.
Date of birth:__________________________ 3. Date of death: _________________________ 4. Sex: _____
5.
Place of birth (City or County): ________________________________________________________________
6.
Father’s full name: __________________________________________________________________________
7.
Mother’s full maiden name: ___________________________________________________________________
8.
Applicant’s name: __________________________________ 9. Telephone #: _________________________
10. Mailing address: ___________________________________________________________________________
11. Your relationship to person named on item #1: ____________________________________________________
12. Purpose for obtaining this record: ______________________________________________________________
_____________________________________________________________________________________________
Signature
Date
Identification Type
ATTACH NOTARIZED AFFIDAVIT AND A PHOTOCOPY OF DRIVER’S LICENSE OR STATE I.D. TO APPLICATION
13. DEATH CERTIFICATE ADDITIONAL IDENTIFYING INFORMATION:
Social Security Number: _____________________________________________________________________
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 & SAFETY CODE, CHAPTER 195, SECTION 195.003).
Fees are subject to change without notice (Call 409-654-3632 for fee verification). For any search of the files where a record is not found, the
searching fee is nonrefundable or transferable. Birth records are confidential for 75 years and death records for 25 years, therefore, issuance is
restricted. Please attach a photocopy of driver’s license or I.D. to application. Administrative rules require that on restricted records, all
identifying information (items 1 – 7), relationship (item 11), and purpose (item 12) be provided in order to issue the record.
FOR OFFICE USE ONLY
Clerk: _____________________________ Received: ________________________ Completed: ________ Pending: ________
CK [ ]
M.O. [ ]
CASH [ ]
INFO: ______________________
Search Fee: [
]
Not Filed Yet: ________
Not Found: ________
Paper Number: __________________________________
tdb 6-1-2016
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