Form Vs-142.3 - Expedited Mail Application For Birth And Death Record - 2015
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OFFICE USE ONLY
OFFICE USE ONLY
Cert #
Remit No.
DOCUMENT CONTROL #
EXPEDITED MAIL APPLICATION
FOR BIRTH AND DEATH RECORD
By______________
ZZ 708-153
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: DSHS - Vital Statistics All funds are deposited directly to the Texas Comptroller of Public
Accounts. For any search of the files where a record is not found, the searching fee is not refundable or transferable.
Birth Certificates
Death Certificates
Type
Cost X
# of copies=
Total
Type
Cost X
# of copies=
Total
st
Certified Copy
$22
1
Copy
$20
0
0
Heirloom-Flag
$60
0
Additional copies
$3
0
(optional) $8 Lone Star OR $19.95 USPS Express Mail
Heirloom-Bassinet
$60
0
($4.95 Priority mail for overseas military address ONLY)
(optional) $8 Lone Star OR $19.95 USPS Express mail
($4.95 Priority mail for overseas military address ONLY)
Expedite fee (required)
$5.00
Expedite fee (required)
$5.00
Total (Check or money order payable to DSHS)
5
Total (Check or money order payable to DSHS)
5
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home
Visitation Program administered by the Office of Early Childhood Coordination of Health and Human Services.
BIRTH/DEATH RECORD INFORMATION
Last Name
First Name
Middle Name
Full Name of
Person on Record
Month
Day
Year
Sex
Date of Birth/Death
City or Town
County
State
Place of Birth/Death
Maiden Name/Last Name
First Name
Middle Name
Full Name of
Parent 1
Maiden Name/Last Name
First Name
Middle Name
Full Name of
Parent 2
REQUESTOR INFORMATION
Telephone #
Email Address
Requestor Name
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 Requestor
Mailing Address for Copies, if Different from Requestor
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)
Your Signature
Date of Application
APPLICATIONS WITHOUT SIGNATURE OF APPLICANT WILL NOT BE PROCESSED.
MAIL THIS APPLICATION, PAYMENT, SWORN STATEMENT AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Texas Vital Records
Department of State Health Services
1100 W. 49th Street
Austin, TX 78756
(APPLICATIONS WITHOUT PHOTO ID AND THE ATTACHED SWORN STATEMENT WILL NOT BE PROCESSED)
Page 1 of 2
VS-142.3 Rev. 09/2015
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