Form Vs-142.3 - Mail Application For Birth And Death Record
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OFFICE USE ONLY
OFFICE USE ONLY
Cert #
Remit No.
DOCUMENT CONTROL #
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
tal Stat st cs All funds are deposited directly to the Te as Comptroller of Public
Accounts
or an search o the iles here a record is not o nd the searchin
ee is not re nda le or trans era le
Birth Certificates
Death Certificates
Type
Cost X
# of copies=
Total
Type
Cost X
# of copies=
Total
$23
Certified Copy
$22
Certified Copy
copy
$2
$21
Heirloom-Flag
$60
Additional Copies
$
$4 each
$60
Heirloom-Bassinet
(optional) $8.00 Lone Star edE OR
(optional) $8.00 Lone Star edE OR
$19.95 USPS Express return delivery
$19.95 USPS Express return delivery
Total
Total
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home
Visitation Pro ram adm n stered by the O ce o Early Ch ldhood Coord nat on o Health and H man Ser ces
I TH E TH ECO
I
O
TIO
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
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent
E
ESTO I
O
TIO
Requestor Name
Telephone #
Email Address
Full Mailing Address
Street Address
City
State
Zip
Purpose for obtaining this record
Relationship to person listed above
I a thor e ma l n to the address belo
I ha e er ed that the address belo
ll rece e my order
Name of Person Receiving Copies, if Different from Requestor
Mailing Address for Copies, if Different from Requestor
City
tate
ip
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 S O
ST TE E T AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Texas Vital Records
Frio County Clerk
Department of State Health Services
500 E. San Antonio St. Box 6
P.O. Box 12040
Pearsall, Texas 78061
ustin T
0 0
(APPLICATIONS WITHOUT PHOTO ID AND THE ATTACHED SWORN STATEMENT WILL NOT BE PROCESSED)
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VS-142.3 Rev.
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