Chambers County Birth/death Record Information Release Form 2015
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1
2Office Use Only
Office Use Only
Heather H. Hawthorne
Volume: ______ Page: ______
Cash
Debit Card
Chambers County Clerk
Document Control #: _______
Check
Credit Card
P.O. Box 728
Security Paper: ____________
Card
By: ______________________
Anahuac, Texas 77514
By: ______________________
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID AND SWORN STATEMENT WHEN SENDING THE
REQUEST. Make check or money orders payable to Chambers County Clerk.
Death Certificates
Birth Certificates
Type
Cost
Copies
Total
Type
Cost
Copies
Total
First certified copy
$21
1
Certified copy
$23
Additional copies
$4
Total
Total
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood development by supporting the Texas
Home Visitation Program administered by the Office of Early Childhood Coordination of Health and Human Services.
BIRTH/DEATH RECORD INFORMATION
Full Name of
First Name
Middle Name
Last Name
Person on Record
Date of
Month
Day
Year
Sex
Birth/Death
Place of
City or Town
County
State
Birth/Death
Full Name of
First Name
Middle Name
Maiden Name/Last Name
Parent 1
Full Name of
First Name
Middle Name
Maiden Name/Last Name
Parent 2
REQUESTOR INFORMATION
Requestor Name
Phone Number
Email Address
Full Mailing Address
Box # or Street Address
City
State
Zip
Relationship to person listed above:
Purpose for obtaining this record:
I authorize mailing to the address below. I have verified the address below will receive my order.
Name of person receiving copies, if different from requestor
Mailing address for copies, if different from requestor
Address
City
State
Zip
WARNING: IT IS A FELONY TO FALSIFY INFORMAITON ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMANT ON THIS
FORM OR FOR SIGNING A FORM WHICH CONTAINS A FASLL STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH
AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
Your Signature _____________________________________
Date of Application ________________
APPLICATIONS WITHOUT SIGNATURE OF APPLICANT, PHOTO ID AND ATTACHED SWORN STATEMENT WILL NOT BE PROCESSED
MAIL THIS APPLICATION, PAYMENT, SWORN STATEMENT AND PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Chambers County Clerk
PO Box 728
Anahuac, TX 77514
Chambers County Birth/Death Certificate Request Form | 1 of 2
Rev. 09/2015
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