Birth Certificate Order Form - Lane County Vital Records

Birth Certificate Order Form

WALK-IN or MAIL TO:

Lane County Vital Records

151 W. 7th Ave., Rm. 520

Eugene, OR 97401

Monday – Friday 9:00 a.m. - 4:30 p.m.

Phone (541) 682-4045 Fax (541) 682-9825

This form is for birth certificates for infants less than 5 months & 28 days of age only.

After 5 months & 28 days we can no longer issue certificates.

You will need to order your child’s birth certificate from:

Oregon State Vital Records located in Portland, Oregon.

DO NOT MAIL CASH

-

CHECKS & MONEY ORDERS PAYABLE TO: LANE COUNTY VITAL RECORDS

SEND A SELF-ADDRESSED ENVELOPE WITH MAIL ORDERS

*

Person ordering: Must attach legible photocopy of current, valid ID or legal representative document.

______

Number of certified records requested.

$25.00 first record / $20.00 each additional of the same record ordered at the same time.

QUANTITY

(1) NAME OF INFANT: _________________________________________________________________________

First

Middle

Last

(2) DATE OF BIRTH: ______________ (3) SEX: _______ (4) PLACE OF BIRTH: _________________________

MM/DD/YYYY

M or F

Hospital / Facility

(5) MOTHER’S FULL MAIDEN NAME:_______________________________________________________________

First

Middle

Maiden

(6) FATHER’S FULL NAME: ______________________________________________________________________

First

Middle

Last

(7) YOUR RELATIONSHIP TO INFANT: MOTHER _______

FATHER _______

SIBILING (18yrs. or older) _______

MATERNAL GRANDPARENT _______

PATERNAL GRANDPARENT _______

LEGAL GUARDIAN ______

(8) *NAME OF PERSON ORDERING:_______________________________________________________________

(9) MAILING ADDRESS: ________________________________________________________________________

CITY: ______________________________ STATE: _____________ ZIP CODE: _____________

(10) SIGNATURE: _____________________________________ (11) PHONE NUMBER: _____________________

In Accordance with law – ORS 432.120, access to birth records is restricted for 100 years to registrant, family members, legal representatives, government agencies and persons

licensed or registered under ORS 703.430. Legal guardians must enclose a copy of the legal document. If you are not eligible, enclose a written permission note with a notarized

signature of an eligible person. Providing false information is a felony under ORS 432.900.

OFFICE USE ONLY. DO NOT WRITE BELOW THIS LINE

OR DL: __________________ Exp. Date: ____________ Pmt Type: Cash / CC / Check-MO# __________________

Passport or Other ID: _______________________________________ Today’s Date: ______________________

Exchange [ ] Returned Cert #s: _____________________ Certificate Number(s):__________________________

Case # :______________________ Order #: _______________________________________________________

Amount Received: $ _____________