Mail Application For Birth And Death Record
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1OFFICE USE ONLY
OFFICE USE ONLY
Birth Certificates
Death Certificates
MAIL APPLICATION FOR
_____________
______________
#342115 - $1.80
#42110 - $21.00
Receipt #
Certificate #
BIRTH AND DEATH RECORD
#42110 - $21.20
#42111 - $1.00
#42111 - $1.00
PLEASE PRINT.
INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: City of Mercedes.
Birth Certificates
Death Certificates
Type
Cost X
# of
Total
Type
Cost X
# of
copies=
copies=
Total
Standard Long form
Certified Copy (1 copy)
$21
$23
Additional Copies
$4
Total
Total
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Last Name
First Name
Middle Name
Full Name of
Person on Record
Date of Birth/Death
Month
Day
Year
Sex
Place of
City or Town
County
State
Birth/Death
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent 1
Maiden Name/Last Name
First Name
Middle Name
Full Name of
Parent 2
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address
Street Address
City
State
Zip
Purpose for obtaining this record:
Relationship to person listed above
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF
COUNTY OF
Before me on this day appeared
(Applicant name)
now residing at
(Address)
(City)
(State)
who is related to the person named on Part I as
and who on oath deposes and says that the contents of this
affidavit are true and correct.
(Relationship)
The applicant presented the following type and number of identification:
Applicant Signature
Sworn to and subscribed before me, this
day of_______
, 20
.
(Seal)
Signature of Notary Public and Notary ID Number_
Typed or Printed Name:
Commission Expires:
Street Address:
City, State, Zip:
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
APPLICATIONS WITHOUT SIGNATURE OF APPLICANT WILL NOT BE PROCESSED
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
City of Mercedes Vital Statistics
PO Box 837
Mercedes, TX 78570
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