Certificate Of Adoption Division Of Vital Records
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1Certificate of Adoption
Division of Vital Records
This information in this section must be given as it was before adoption. Without this data it may be impossible to
PART I
prepare an amended certificate of birth for this child.
NAME OF CHILD - First Name
Middle Name
Last Name
Date of Birth
Sex
Race
FACTS
OF
BIRTH
County of Birth
State or Foreign Country of Birth
Maiden name of Mother - First Name
Middle Name
Last Name (Maiden Surname)
NATURAL
PARENTS
Name of Father - First Name
Middle Name
Last Name
DATA
Signature of person verifying data in Part I
Authorization (attorney, clerk of court, agency director, other (specify)
VERIFICATION
OF PART I
Adopting parents must furnish the following information concerning themselves as it was at the date of birth of the
PART II
above child. This information is used in preparation of the amended certificate of birth.
Mother's Current Legal Name - First Name Middle Name
Last
Suffix
Maiden Name of Mother - First Name
Middle Name
Last Name (Maiden Surname)
MOTHER
Date of Birth - Month, Day, Year
Birthplace (State of Foreign Country)
Color or Race
Residence - City or Town
County
State
Name of Father - First Name
Middle Name
Last Name
FATHER
Date of Birth - Month, Day, Year
Birthplace (State or Foreign Country)
Color or Race
Occupation
Kind of Business or Industry
Signature:
VERIFICATION
NOTE: Where the spouse of the child's natural parent (i.e. the
OF
Mother
child's stepparent) is the adopting parent, for the purpose
PART II
of completing this form, both the stepparent and the
Father
natural parent will be considered the adopting parents.
Prior relationship between adopting parent(s) and adopted child:
MOTHER:
Stepmother
Grandmother
Natural Mother
Aunt
Other (specify):
FATHER:
Stepfather
Grandfather
Natural Father
Uncle
Other (specify):
Name and mailing address of agency or department which investigated or handled case.
AGENCY OR
DEPARTMENT
Name and mailing address of Attorney
ATTORNEY
To Be Completed by the Clerk of Court
I hereby certify that the foreign adoption of the child by the parents named in Part II above and described in the order
PART III
made on the
and recorded in Judgement Roll or Docket No.
DOMESTICATION
OF FOREIGN
was domesticated and is now to bear the name of
as set forth in the order.
ADOPTION
Signature and Seal of Clerk of Court
Date signed
Clerk of Court in and for the County of
State of
I hereby certify that the child described in the decree of adoption made on the
and
recorded in Judgement Roll or Docket No.
was adopted by the parent(s) named in Part II and is
PART IV
now to bear the name of
as set forth in the order.
SC
ADOPTION
Signature and Seal of Clerk of Court
Date signed
Clerk of Court in and for the County of
State of
When birth occurred in a state other than South Carolina the State Registrar shall forward this certificate to the proper
PART V
official in the state of birth.
Certification of
I hereby certify that this report of adoption was received on the
S.C. Dept. of Health &
Env. Control
Signature
Title
DHEC 0671 (Rev. 02/2005)
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