"Birth Certificate Application Form" - Minnesota (Karen)

This is a legal document that was released by the Minnesota Department of Health - a government authority operating within Minnesota.

The document is provided in Karen.

Form Details:

  • Released on February 16, 2018;
  • The latest edition currently provided by the Minnesota Department of Health;
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  • Compatible with most PDF-viewing applications;

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vD R IAzJ v Xw>rReD . rRCgrh > w>td . zsgvXurs X >us g M.<Aw>*h > w>usd R 'D ; w>td . zsJ . tvH m tk . o;-uX;0J b .0J ' D ; yS R w*Rv>v>vXAtzd ; oJ p ;'D ; w>*h > cd . wD e D . *H > A 1A
wk R A 19A vX t td . zsg 0J A'f v m tH R tod ; M.vD R IAw>rReD . rRCgt*k R *RvXt&h ' d . wz.w>ym0J ' f t rh > w>cl o l . tod ; M.vD R IAw>xXzS d . rReD . w>*h > b.C;'D ; yd m rk . vX
ttd . zsJ . tzd < AvXt wzsD t o;'D ; zd o .ty>zJ v Xt'XxD . Arh w rh > Atd . zsJ . xD . zd o .t0J M .tcg<Aw>ym0J ' f t rh > w>*h > cl o l . tod ; rh w rh > b.vXrd > teD > up>'.0J ym
zsgxD . 0J v Xurs X >tusgzJ v Xw>qJ ; vD R rH R rReD . w>td . zsJ . t*h > tcgM.vD R IAzJ w >ymw>rReD . rRCgA'f t rh > w>*h > cl o l . tcg<Aw>uzD . CH ; Cm0J ' .w>*h > w> usd R 'D ;
w>td . zsJ . tvH m tk . o;'D ; yS R vXtb.w>ymzsgtD R 'f w >*h > cd . wD e D . *H > A20Awk R A24A'f v mtH R tod ; M.vD R I
vXw>ub.vl R yd m rRxG J 0 J A =ArReD . vD R w>vXwvg'Xzd t yl R vXw>ymzsgxD . ew>&h v d m b.xG J ' D ; yS R vXtb.w>rReD . t*h > 'f v mtH R tod ; wuh > I
w>td . zsJ . tvH m tk . o;td . 0J v XAyS R w*Rv>v>vXAtzd ; oJ p ;'D ; w>*h > cd . wD e D . *H > A1Awk R A19AvXt td . zsg 0J 'f v m tH R tod ; A(w>rReD . vXw>ymzs g vXursX>usg)
1. ☐ rd > y>w*RtrH R vXyS R b.xG J ' D ; AyS R w*Rtw>rReD . rRCgtyl R
2. ☐ yS R vXtb.xG J ' D ; w>*h > tzH t zk
3. ☐ yS R vXtb.xG J ' D ; w>*h > tzH t zk z ;'d .
4. ☐ yS R vXtb.xG J ' D ; w>*h > tzd
5. ☐ yS R vXtb.xG J ' D ; w>*h > tvH R
6. ☐ yS R vXtb.xG J ' D ; w>*h > tvd R
7. ☐ yS R vXtb.xG J ' D ; w>*h > trg§0RA(eub.rh > t'D r g0RvXuwD > tH R )
8. ☐ yS R vXtb.xG J ' D ; w>*h > tw>rReD . vXt&h ' d . A(,Ch x D . ,eD > up>'.,J , w>td . zs J . tw>rReD . )
9. ☐ u&XvXt[H ; rl ' gxXEk m vD R w>rReD . A(yS R oh y S R b.vXtul p gw>td . ql . td . cVxD & D R Arh w rh > AyS R 'k ; td . zs J . zd )
10. ☐ yS R vXtb.C;'D ; w>*h > AtyS R M>cG J ; uG > xG J w >zd ; oJ p ;<AyS R uG > xG J w >Arh w rh > AyS R uG > uwJ m uwD R w>zd A(ub.td . 'D ; uG D > bs D . w>uvk > vXw>ud ; M>erH R w>tk . o;tw>uG J ; 'd )
11. ☐ yS R vXtb.xG J ' D ; w>*h > tyS R cX.p;vXtuG > xG J w >td . ql . td . cV A(ub.td . 'D ; yD > &D t w>tk . o;b.C;w>uG > xG J w >td . ql . td . cV)
12. ☐ yS R vXtb.xG J ' D ; w>*h > teD > up>'.0J t cX.p;<Aub.td . 'D ; w>tk . o;tw>uG J ; 'd v Xw>yXqS X w>pk v D > cD . cd . t*D >
13. ☐ yS R vXtxD . b.yS R vXtb.xG J ' D ; w>*h > tvD > A(yS R vXtb.xG J ' D ; w>*h > oH ) <Aub.td . 'D ; w>tk . o;tw>uG J ; 'd v Xw>yXqS X uG > xG J w >pk v D > cD . cd . t*D >
14. ☐ w>qXwJ m ymvD R o;Arh w rh > Aw>'D o 'XvD R eD > up>'.0J A rh w rh > Aw>pk v D > cD . cd . tw>cG J ; w>,m'D ; vd . b.w>tk . o;vXw>td . zsJ . tvH m tk . o;t*D >
15. ☐ u&XcX.p;vXtuG > vk > zd w >A=AvXw>rR0H R w>Ck o h . ngw>uG > vk > zd t cD . xH ; cD . bd A (ub.td . 'D ; yS R rRw>zd t ID AeD . *H > )
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18. ☐ w>tk . o;tw>uG J ; 'd b .C;w>vl R yd m rRxG J ' f u D > trJ & uRuG D > bsD . w>uvk > trh > twD t od ; A(wrh > uG D > bs D . tw>ud ; )AvXtbd ; b.&RvD R b.C;w>tk . o;
19. ☐ cX.p;vXtM>pd M >urD R 'f t zs g 0J z J e D . *H > A1Awk R A14A(ub.td . 'D ; yS R vXtM>pd M >urD R vXw>ysJ v D R ql e td . tw>qJ ; vD R rH R vXw>ymzsgtyl R )
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20. ☐ rd > y>trH R td . vXyS R vXtb.xG J ' D ; w>*h > tw>rReD . rRCgtyl R
21. ☐ yS R uG > xG J ' D o 'Xw>zd < AyS R u[k u ,mw>zd A rh w rh > AyS R uG > uwJ m uwD R w>zd v XtuG > xG J yS R vXtb.xG J z d ; oJ p ;A(ub.td . 'D ; uG D > bsD . w>uvk > vXw>ud ; M>erH R w>tk . o;tw>uG J ; 'd )
22. ☐ yS R vXtb.xG J ' D ; w>*h > <AzJ v X
to;eH . A16AeH . Arh w rh > A16AeH . ql t zD c d .
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Page 1 of 2
OFFICE OF VITAL RECORDS
rev 2/16/18 - Karen
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wk R A 19A vX t td . zsg 0J A'f v m tH R tod ; M.vD R IAw>rReD . rRCgt*k R *RvXt&h ' d . wz.w>ym0J ' f t rh > w>cl o l . tod ; M.vD R IAw>xXzS d . rReD . w>*h > b.C;'D ; yd m rk . vX
ttd . zsJ . tzd < AvXt wzsD t o;'D ; zd o .ty>zJ v Xt'XxD . Arh w rh > Atd . zsJ . xD . zd o .t0J M .tcg<Aw>ym0J ' f t rh > w>*h > cl o l . tod ; rh w rh > b.vXrd > teD > up>'.0J ym
zsgxD . 0J v Xurs X >tusgzJ v Xw>qJ ; vD R rH R rReD . w>td . zsJ . t*h > tcgM.vD R IAzJ w >ymw>rReD . rRCgA'f t rh > w>*h > cl o l . tcg<Aw>uzD . CH ; Cm0J ' .w>*h > w> usd R 'D ;
w>td . zsJ . tvH m tk . o;'D ; yS R vXtb.w>ymzsgtD R 'f w >*h > cd . wD e D . *H > A20Awk R A24A'f v mtH R tod ; M.vD R I
vXw>ub.vl R yd m rRxG J 0 J A =ArReD . vD R w>vXwvg'Xzd t yl R vXw>ymzsgxD . ew>&h v d m b.xG J ' D ; yS R vXtb.w>rReD . t*h > 'f v mtH R tod ; wuh > I
w>td . zsJ . tvH m tk . o;td . 0J v XAyS R w*Rv>v>vXAtzd ; oJ p ;'D ; w>*h > cd . wD e D . *H > A1Awk R A19AvXt td . zsg 0J 'f v m tH R tod ; A(w>rReD . vXw>ymzs g vXursX>usg)
1. ☐ rd > y>w*RtrH R vXyS R b.xG J ' D ; AyS R w*Rtw>rReD . rRCgtyl R
2. ☐ yS R vXtb.xG J ' D ; w>*h > tzH t zk
3. ☐ yS R vXtb.xG J ' D ; w>*h > tzH t zk z ;'d .
4. ☐ yS R vXtb.xG J ' D ; w>*h > tzd
5. ☐ yS R vXtb.xG J ' D ; w>*h > tvH R
6. ☐ yS R vXtb.xG J ' D ; w>*h > tvd R
7. ☐ yS R vXtb.xG J ' D ; w>*h > trg§0RA(eub.rh > t'D r g0RvXuwD > tH R )
8. ☐ yS R vXtb.xG J ' D ; w>*h > tw>rReD . vXt&h ' d . A(,Ch x D . ,eD > up>'.,J , w>td . zs J . tw>rReD . )
9. ☐ u&XvXt[H ; rl ' gxXEk m vD R w>rReD . A(yS R oh y S R b.vXtul p gw>td . ql . td . cVxD & D R Arh w rh > AyS R 'k ; td . zs J . zd )
10. ☐ yS R vXtb.C;'D ; w>*h > AtyS R M>cG J ; uG > xG J w >zd ; oJ p ;<AyS R uG > xG J w >Arh w rh > AyS R uG > uwJ m uwD R w>zd A(ub.td . 'D ; uG D > bs D . w>uvk > vXw>ud ; M>erH R w>tk . o;tw>uG J ; 'd )
11. ☐ yS R vXtb.xG J ' D ; w>*h > tyS R cX.p;vXtuG > xG J w >td . ql . td . cV A(ub.td . 'D ; yD > &D t w>tk . o;b.C;w>uG > xG J w >td . ql . td . cV)
12. ☐ yS R vXtb.xG J ' D ; w>*h > teD > up>'.0J t cX.p;<Aub.td . 'D ; w>tk . o;tw>uG J ; 'd v Xw>yXqS X w>pk v D > cD . cd . t*D >
13. ☐ yS R vXtxD . b.yS R vXtb.xG J ' D ; w>*h > tvD > A(yS R vXtb.xG J ' D ; w>*h > oH ) <Aub.td . 'D ; w>tk . o;tw>uG J ; 'd v Xw>yXqS X uG > xG J w >pk v D > cD . cd . t*D >
14. ☐ w>qXwJ m ymvD R o;Arh w rh > Aw>'D o 'XvD R eD > up>'.0J A rh w rh > Aw>pk v D > cD . cd . tw>cG J ; w>,m'D ; vd . b.w>tk . o;vXw>td . zsJ . tvH m tk . o;t*D >
15. ☐ u&XcX.p;vXtuG > vk > zd w >A=AvXw>rR0H R w>Ck o h . ngw>uG > vk > zd t cD . xH ; cD . bd A (ub.td . 'D ; yS R rRw>zd t ID AeD . *H > )
16. ☐ vD > u0D R
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uD > pJ .
uD > pXzS d . y'd . cX.p;u&X (ub.td . 'D ; yS R rRw>zd t ID AeD . *H > )
17. ☐ yD > &D A =A,rH . eH . pd x .yD > &D t vH m w>ysJ e D . *H > rh > 0J = ___________ wrh > rH . eH . pd x .tvH m w>ys J I AxXEk m Ck m tw>uG J ; 'd
18. ☐ w>tk . o;tw>uG J ; 'd b .C;w>vl R yd m rRxG J ' f u D > trJ & uRuG D > bsD . w>uvk > trh > twD t od ; A(wrh > uG D > bs D . tw>ud ; )AvXtbd ; b.&RvD R b.C;w>tk . o;
19. ☐ cX.p;vXtM>pd M >urD R 'f t zs g 0J z J e D . *H > A1Awk R A14A(ub.td . 'D ; yS R vXtM>pd M >urD R vXw>ysJ v D R ql e td . tw>qJ ; vD R rH R vXw>ymzsgtyl R )
w>td . zsJ . tvH m tk . o;rh > '.xJ v XyS R vXttd . vXw>td . o;tzD v mArh w rh > AyS R trH R td . zsgvXvmwz.t*D > {d R A(w>rReD . vXw>ym0J ' f t rh > w>cl o l . )
20. ☐ rd > y>trH R td . vXyS R vXtb.xG J ' D ; w>*h > tw>rReD . rRCgtyl R
21. ☐ yS R uG > xG J ' D o 'Xw>zd < AyS R u[k u ,mw>zd A rh w rh > AyS R uG > uwJ m uwD R w>zd v XtuG > xG J yS R vXtb.xG J z d ; oJ p ;A(ub.td . 'D ; uG D > bsD . w>uvk > vXw>ud ; M>erH R w>tk . o;tw>uG J ; 'd )
22. ☐ yS R vXtb.xG J ' D ; w>*h > <AzJ v X
to;eH . A16AeH . Arh w rh > A16AeH . ql t zD c d .
23. ☐ rH . eH . pd x .w>wd m usJ R tcX.p;vXtyXqS X &J . usJ R w>qD . xG J r RpXRzd o .<AuoH . uoD w >ul p gtw>rRpXR< MinnesotaCare A'D ; w>rRpXRwz.vXttd . vX rH . eH . pd x .w> od . w>
oD t zD v m<AtqXzd A124D.23A'D ; A626.556AM.vD R IA(ub.td . 'D ; yS R rRw>zd t ID AeD . *H > )
24. ☐ w>tk . o;tw>uG J ; 'd b .C;w>vl R yd m rRxG J ' f u D > trJ & uRuG D > bsD . w>uvk > trh > twD t od ; A(wrh > uG D > bsD . tw>ud ; )AvXtbd ; b.&RvD R b.C;w>tk . o;
Page 1 of 2
OFFICE OF VITAL RECORDS
rev 2/16/18 - Karen
w>ywH x D . w>td . zsJ . vH m tk . o;tw>uG J ; 'd
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Vital Records
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Minnesota Department of Health
Central Cashiering – Vital Records
PO Box 64499
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St. Paul MN 55164-0499
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FAX
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OFFICE OF VITAL RECORDS
rev 2/16/18 - Karen
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