Texas Department Of State Health Services Application For Certified Copy Of Birth Or Death Record
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2TEXAS VITAL STATISTICS
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
P.O. BOX 12040
AUSTIN, TEXAS 78711-2040
PHONE (888) 963-7111
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH RECORD
Birth Certificates
Death Certificates
PLEASE PRINT
See Reverse Side for Instructions
# REQUESTED
# REQUESTED
___ CERTIFIED COPIES
X
$22.00 ____
___ CERTIFIED COPY
X
$20.00 _____
___ WALLET-SIZE
X
$22.00 ____
___ EXTRA COPIES
OF SAME RECORD
X
$3.00 _____
___ HEIRLOOM
X
$60.00 ____
TOTAL ENCLOSED = __________
TOTAL ENCLOSED = __________
First Name
Middle Name
Last Name
1. Full Name of
Person on Record
Month
Day
Year
Sex
2. Date of
Birth or Death
Male
Female
City or Town
County
State
3. Place of
Birth or Death
First Name
Middle Name
Last Name
4. Full Name of
Father
First Name
Middle Name
Maiden Name
5. Full Maiden
Name of Mother
6. YOUR NAME: ____________________________________________________ 7. TELEPHONE #: _(____)__________________
8. MAILING ADDRESS: _______________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
9. RELATIONSHIP TO PERSON NAMES IN ITEM 1: _______________________________________________________________
10. PURPOSE FOR OBTAINING THIS RECORD: __________________________________________________________________
11. ADDITIONAL IDENTIFYING FOR DEATH CERTIFICATE
SOCIAL SECURITY NUMBER OF DECEASED ____________________________
BIRTHDATE _________________________
BIRTH PLACE, ECT. ________________________________________________
Fees are subject to change without notice (call 512-458-7111 for fee verification). For any search of the files where a record is not
found, the searching fee is not refundable or transferable.
You can expect to receive you certificate within 6-8 weeks.
This fee rate(s) was set by the Texas Board of Heath and was not mandated by the Texas Legislature.
Birth records are confidential for 75 years and death records for 25 years; therefore, issuance is restricted.
Administrative rules require that on restricted records, all identifying information (Item 1-5), relationship (Item 9), and purpose (Item10)
be provided in order to issue the record.
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS
IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
ATTACH PHOTOCOPY OF VALID IDENTIFICATION. APPLICATION WILL NOT BE
PROCESSED WITHOUT IDENTIFICATION.
YOUR SIGNATURE
DATE OF APPLICATION
IDENTIFICATION TYPE ____________________________________________
NUMBER _____________________
VS-141 REV. 12/2005
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