Mail-In Application For Certified Copy Of Birth Or Death Certificate Form 2015 (Page 2 of 2) in pdf

Mail-In Application For Certified Copy Of Birth Or Death Certificate Form 2015 Page 2

NOTARIZED PROOF OF IDENTIFICATION

PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION

APPEARS ON BIRTH/DEATH CERTIFICATE

FULL NAME OF PERSON ON RECORD

DATE OF BIRTH/DEATH

PLACE OF BIRTH/DEATH (City or County)

SEX

FULL NAME OF PARENT 1

FULL NAME OF PARENT 2

PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED

NAME AND RELATIONSHIP TO PERSON ON RECORD

TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED

AFFIDAVIT OF PERSONAL KNOWLEDGE

PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC

STATE OF _________________

COUNTY OF _______________

Before me on this day appeared __________________________________________________________

(Name)

Now residing at_______________________________________________________________________

(Address)

(City)

(State)

Who is related to the person named on Part I as ____________________________________________

(Relationship)

and who on oath deposes and says that the contents of this affidavit are true and correct.

Signature_______________________________________

Sworn to and subscribed before me, this ______day of ____________________, 20_______

Signature of Notary Public

Commission Expires

Typed or Printed Name

(Seal)

Street Address

City, State and 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)

MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND PHOTOCOPY OF YOUR VALID ID TO:

SHERRY LEMON, WISE COUNTY CLERK

P.O. BOX 359

200 N. TRINITY

DECATUR, TX 76234

(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)

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Mail-In Application For Certified Copy Of Birth Or Death Certificate Form 2015 Page 2