"Mail Application for Birth and Death Record" - City of Corpus Christi, Texas

This fillable "Mail Application for Birth and Death Record" is a document issued by the City of Corpus Christi Health District specifically for Texas residents.

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Download "Mail Application for Birth and Death Record" - City of Corpus Christi, Texas

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MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make money orders payable to: City of Corpus Christi
For any search of the files where a record is not found, lhe searching fee is not refundable or
transferable.
Birth
$23.00
per
copy
#
Requested!
Total Due$
Death
$21 .00
for
the first copy,
$4.00 each additional copy
#
Requested:
Total Due$
D
I wish to make a
v
oluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas
Home Visitation Program administered by the Office ofearly Chlldhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION {PART 1)
.
Full Name of
Person on record
First Name
Middle Name
Last Name
Date of Birth/Death
Month
Day
I
Year
Sex
Place of
City or Town
County
Slate
Birth/Death
(Death
cemficales
Corpus CllrtsU
ONLYI
TEXAS
Full Name of
Parent 1
First Name
Mlddle Name
Maiden Name/Last Name
Full Name of
Parenl 2
First Name
Middle Name
Malden Name/Last Name
APPLICANT INFORMATION (PART II)
Applicant Name
!Telephone#
Full Mailing Address
Street Address
City
State
Relationship to person listed above
!Purpose for obtaining this
record:
01
authorize malling to the address below. I have verified that the address below
will receive my order.
Name of Person Receiving Coples, If Different from Applicant
Mailing Address for Coples, If Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (PART Ill)
STATE OF
COUNTY OF
Before me on this day appeared
Zip
(Applicant Name)
now residing at
(Address)
(City)
(State)
who Is related lo lhe person named on Part
J
as
and who on oath deposes and says that the contents of this
affidavit are true and correct.
(Relationship)
The applicant presented the foliov..ing type and number of Identification:
Applicant Signature
Sworn to and subscribed before me, this
day of
• 20
Signature of Notary Public and Notary ID Number
Typed of Printed Name:
Commission Expires:
Street Address:
City, State, Zip:
(Seal)
WARNING;
IT IS
A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING FALSE STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISIONMENT AND A FINE OF UPTO $10,000. (HEALTH AND SAFETY CODE.CHAPTER 195, SEC. 195.003
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
CORPUS CHRISTI VITAL RECORDS
1702 HORNE ROAD, ROOM 21
CORPUS CHRISTI, TEXAS 78416
MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make money orders payable to: City of Corpus Christi
For any search of the files where a record is not found, lhe searching fee is not refundable or
transferable.
Birth
$23.00
per
copy
#
Requested!
Total Due$
Death
$21 .00
for
the first copy,
$4.00 each additional copy
#
Requested:
Total Due$
D
I wish to make a
v
oluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas
Home Visitation Program administered by the Office ofearly Chlldhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION {PART 1)
.
Full Name of
Person on record
First Name
Middle Name
Last Name
Date of Birth/Death
Month
Day
I
Year
Sex
Place of
City or Town
County
Slate
Birth/Death
(Death
cemficales
Corpus CllrtsU
ONLYI
TEXAS
Full Name of
Parent 1
First Name
Mlddle Name
Maiden Name/Last Name
Full Name of
Parenl 2
First Name
Middle Name
Malden Name/Last Name
APPLICANT INFORMATION (PART II)
Applicant Name
!Telephone#
Full Mailing Address
Street Address
City
State
Relationship to person listed above
!Purpose for obtaining this
record:
01
authorize malling to the address below. I have verified that the address below
will receive my order.
Name of Person Receiving Coples, If Different from Applicant
Mailing Address for Coples, If Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (PART Ill)
STATE OF
COUNTY OF
Before me on this day appeared
Zip
(Applicant Name)
now residing at
(Address)
(City)
(State)
who Is related lo lhe person named on Part
J
as
and who on oath deposes and says that the contents of this
affidavit are true and correct.
(Relationship)
The applicant presented the foliov..ing type and number of Identification:
Applicant Signature
Sworn to and subscribed before me, this
day of
• 20
Signature of Notary Public and Notary ID Number
Typed of Printed Name:
Commission Expires:
Street Address:
City, State, Zip:
(Seal)
WARNING;
IT IS
A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING FALSE STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISIONMENT AND A FINE OF UPTO $10,000. (HEALTH AND SAFETY CODE.CHAPTER 195, SEC. 195.003
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
CORPUS CHRISTI VITAL RECORDS
1702 HORNE ROAD, ROOM 21
CORPUS CHRISTI, TEXAS 78416
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