"Application Form for Certified Copy of Birth or Death Certificate" - County of Ector, Texas

Application Form for Certified Copy of Birth or Death Certificate is a legal document that was released by the Texas Department of State Health Services - a government authority operating within Texas. The form may be used strictly within County of Ector.

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Download "Application Form for Certified Copy of Birth or Death Certificate" - County of Ector, Texas

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Linda Haney
Ector County Clerk
PO Box 707
Odessa TX 79760
432-498-4130
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
Money orders/Cashier’s checks only
                     
 
 
 
 
 
Birth Certificate
Death Certificate
____# Requested @ $23.00
_____First Copy @ $21.00 _____ Additional @ $4.00
Birth Form #_____________ State Form #___________
Birth Form #_____________State Form #__________
Vol______Page________ Registrar #______________
Vol_____Page______
Registrar #____________
Deputy_______________________________________
Deputy______________________________________
WARNING: The penalty for knowingly making a false statement on this form can be 2-10 years in prison and a fine of
up to $10,000.00 (Health & Safety Code 195.003)
 
Please Print:
Information Found on Birth/Death Certificate
 
1.
Full Name on Record: (first, middle, last)
 
2.
Date of Birth/Death:
 
3.
Place of Birth/Death: (City, County)
 
4.
Parent 1 Full Name:
Maiden/Birth Last Name
 
5.
Parent 2 Full Name:
Maiden/Birth Last Name
 
 
 
Information about Applicant
 
6.
Applicant’s Full Name:
 
7.
Applicant’s Mailing Address:
 
City, State, Zip Code
 
8.
Telephone Number:
9. Email Address
 
10.
Applicant’s Relationship to Person Named in #1:
 
11.
Purpose for Obtaining Record:
 
 
 
I wish to make a $5 donation for the Texas Home Visiting Program for healthy early childhood
 
 
Signature of Applicant
Today’s Date
(COPY OF APPLICANT’S PHOTO ID IS REQUIRED)
For applications that are sent by mail:
The attached Notarized Proof of Identification/Affidavit of Personal Knowledge and copy of valid photo ID must be attached to
this completed application or the request will not be processed.
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Linda Haney
Ector County Clerk
PO Box 707
Odessa TX 79760
432-498-4130
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
Money orders/Cashier’s checks only
                     
 
 
 
 
 
Birth Certificate
Death Certificate
____# Requested @ $23.00
_____First Copy @ $21.00 _____ Additional @ $4.00
Birth Form #_____________ State Form #___________
Birth Form #_____________State Form #__________
Vol______Page________ Registrar #______________
Vol_____Page______
Registrar #____________
Deputy_______________________________________
Deputy______________________________________
WARNING: The penalty for knowingly making a false statement on this form can be 2-10 years in prison and a fine of
up to $10,000.00 (Health & Safety Code 195.003)
 
Please Print:
Information Found on Birth/Death Certificate
 
1.
Full Name on Record: (first, middle, last)
 
2.
Date of Birth/Death:
 
3.
Place of Birth/Death: (City, County)
 
4.
Parent 1 Full Name:
Maiden/Birth Last Name
 
5.
Parent 2 Full Name:
Maiden/Birth Last Name
 
 
 
Information about Applicant
 
6.
Applicant’s Full Name:
 
7.
Applicant’s Mailing Address:
 
City, State, Zip Code
 
8.
Telephone Number:
9. Email Address
 
10.
Applicant’s Relationship to Person Named in #1:
 
11.
Purpose for Obtaining Record:
 
 
 
I wish to make a $5 donation for the Texas Home Visiting Program for healthy early childhood
 
 
Signature of Applicant
Today’s Date
(COPY OF APPLICANT’S PHOTO ID IS REQUIRED)
For applications that are sent by mail:
The attached Notarized Proof of Identification/Affidavit of Personal Knowledge and copy of valid photo ID must be attached to
this completed application or the request will not be processed.
Page 1 of 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 in Part I as __________________________________________ and who on oath deposes
(relationship)
and says that the contents of this affidavit are true and correct.
Signature ______________________________________
Sworn to and subscribed before me, this _____ day of ______________, 20 ____.
(Please place notary stamp in space below)
Signature of Notary Public
Matricula card is not an acceptable
Commission Expires
form of identification.
Typed or Printed Name
Street Address
City, State and Zip
WARNING: IT 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 (MONEY ORDER OR CASHIER CHECK) AND A PHOTOCOPY OF YOUR VALID
PHOTO ID TO:
ECTOR COUNTY CLERK
VITAL RECORDS
PO BOX 707
ODESSA TX 79760
(APPLICATION WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
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