"Application for a Certified Birth Certificate" - Chemung County, New York

Application for a Certified Birth Certificate is a legal document that was released by the Health Department - Chemung County, New York - a government authority operating within New York. The form may be used strictly within Chemung County.

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CHEMUNG COUNTY VITAL STATISTICS
Application for a Certified Birth Certificate
To prevent a delay or denial of your order, read the following information before completing this
application: Certified Birth Certificates, Acceptable ID and Documented Proof of Entitlement, and
Cost & Payment Options. Fees are not refundable.
Please print certificate information:
__________________________________________
_____
___/ __/_____
Name as it appears on the record: First Middle Last
Date of Birth
___________________________________
City, Town or Village where birth occurred.
Must be in Chemung County
___________________________________
________________________________
Full maiden name of mother listed
Full name of father listed
Number of certificates requested: ____________
Certificate fees: $15.00 for one certificate, $10.00 for each additional certificate of the same record.
Acceptable forms of payment: Money order or certified check made payable to Chemung County Vital Records, credit
or debit. No personal checks.
Debit/Credit Payment Information:
Complete this section only if the applicant is the cardholder; otherwise, skip
payment information on this application and complete a notarized Consent to Charge Credit/Debit Account form to
include with this application. Debit/Credit payments subject to minimum $2 service charge.
_______________________________________________
Name as it appears on credit/debit card.
_____________________________________
_________________
____________________
Account #
Expiration Date
3 or 4 Digit Security Code
____________________________
________________________________
___________________________________
__________________________________________
___________________________________
__________________________________________
Mailing address
Billing address, if different than mailing
________________________________________________________________________________
Name of Applicant: ________________________________ Phone No.: ________________________
Please print
Relationship to person whose record is required: □Self, □Parent, □ other; specify _________________
If applicable, be sure to enclose required document showing proof of entitlement or Consent to Release Certified Birth
Certificate form.
Signature: ______________________________________________ Date: _______________
**Signature must be notarized if your current mailing address is not listed on your driver’s/non-driver’s license
or if you are requesting that the certificate be mailed to a different address.
otary stamp/seal:
__________________________________
N
Notary Signature & date
CHEMUNG COUNTY VITAL STATISTICS
Application for a Certified Birth Certificate
To prevent a delay or denial of your order, read the following information before completing this
application: Certified Birth Certificates, Acceptable ID and Documented Proof of Entitlement, and
Cost & Payment Options. Fees are not refundable.
Please print certificate information:
__________________________________________
_____
___/ __/_____
Name as it appears on the record: First Middle Last
Date of Birth
___________________________________
City, Town or Village where birth occurred.
Must be in Chemung County
___________________________________
________________________________
Full maiden name of mother listed
Full name of father listed
Number of certificates requested: ____________
Certificate fees: $15.00 for one certificate, $10.00 for each additional certificate of the same record.
Acceptable forms of payment: Money order or certified check made payable to Chemung County Vital Records, credit
or debit. No personal checks.
Debit/Credit Payment Information:
Complete this section only if the applicant is the cardholder; otherwise, skip
payment information on this application and complete a notarized Consent to Charge Credit/Debit Account form to
include with this application. Debit/Credit payments subject to minimum $2 service charge.
_______________________________________________
Name as it appears on credit/debit card.
_____________________________________
_________________
____________________
Account #
Expiration Date
3 or 4 Digit Security Code
____________________________
________________________________
___________________________________
__________________________________________
___________________________________
__________________________________________
Mailing address
Billing address, if different than mailing
________________________________________________________________________________
Name of Applicant: ________________________________ Phone No.: ________________________
Please print
Relationship to person whose record is required: □Self, □Parent, □ other; specify _________________
If applicable, be sure to enclose required document showing proof of entitlement or Consent to Release Certified Birth
Certificate form.
Signature: ______________________________________________ Date: _______________
**Signature must be notarized if your current mailing address is not listed on your driver’s/non-driver’s license
or if you are requesting that the certificate be mailed to a different address.
otary stamp/seal:
__________________________________
N
Notary Signature & date