"Birth Certificate Order Form" - Lane County, Oregon

"Birth Certificate Order Form" - Lane County, Oregon Download Pdf
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Birth Certificate Order Form is a legal document that was released by the Health and Human Services - Lane County, Oregon - a government authority operating within Oregon. The form may be used strictly within Lane County.

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Birth Certificate Order Form
WALK-IN or MAIL TO:
Lane County Vital Records
151 W. 7th Ave., Rm. 520
Eugene, OR 97401
Monday – Friday 9:00 a.m. - 4:30 p.m.
Phone (541) 682-4045 Fax (541) 682-9825
This form is for birth certificates for infants less than 5 months & 28 days of age only.
After 5 months & 28 days we can no longer issue certificates.
You will need to order your child’s birth certificate from:
Oregon State Vital Records
located in Portland, Oregon.
DO NOT MAIL CASH
- CHECKS & MONEY ORDERS PAYABLE TO: LANE COUNTY VITAL RECORDS
SEND A SELF-ADDRESSED ENVELOPE WITH MAIL ORDERS
*
Person ordering: Must attach legible photocopy of current, valid ID or legal representative document.
________
Number of certified records requested.
QUANTITY
$25.00 first record / $20.00 each additional of the same record ordered at the same time.
(1) Name of Infant:
First
Middle
Last
(2) Date of Birth: _______________ (3) SEX:
Male
Female
(4) Place of Birth:
MM / DD / YYYY
Hospital / Facility
(5) Mother’s Full Maiden Name: ___________________________________________________________________________________
First
Middle
Maiden Last Name
(6) Father’s Full Name: __________________________________________________________________________________________
First
Middle
Last
(7) Your Relationship to Infant:
Mother
Father
Sibling (18yrs. or older)
Maternal Grandparent
Paternal Grandparent
Legal Guardian
(8) *Name of Person Ordering: ____________________________________________________________________________________
(9) Mailing Address: ___________________________________________________________________________________________
City: _____________________________________ State: ___________________ Zip Code: ____________________
(10) Signature: __________________________________________________ (11) Phone Number: _____________________________
In Accordance with law – ORS 432.120, access to birth records is restricted for 100 years to registrant, family members, legal representatives, government agencies and persons licensed or registered under ORS 703.430. Legal
guardians must enclose a copy of the legal document. If you are not eligible, enclose a written permission note with a notarized signature of an eligible person. Providing false information is a felony under ORS 432.900.
OFFICE USE ONLY. DO NOT WRITE BELOW THIS LINE
OR DL: __________________ Exp. Date: ____________ Pmt Type: Cash / CC / Check-MO# __________________
Passport or Other ID: _______________________________________ Today’s Date: ______________________
Exchange
Returned Cert #s: _____________________ Certificate Number(s):__________________________
Case # :______________ Order #: _________________________________Amount Received: $ ______________
Birth Certificate Order Form
WALK-IN or MAIL TO:
Lane County Vital Records
151 W. 7th Ave., Rm. 520
Eugene, OR 97401
Monday – Friday 9:00 a.m. - 4:30 p.m.
Phone (541) 682-4045 Fax (541) 682-9825
This form is for birth certificates for infants less than 5 months & 28 days of age only.
After 5 months & 28 days we can no longer issue certificates.
You will need to order your child’s birth certificate from:
Oregon State Vital Records
located in Portland, Oregon.
DO NOT MAIL CASH
- CHECKS & MONEY ORDERS PAYABLE TO: LANE COUNTY VITAL RECORDS
SEND A SELF-ADDRESSED ENVELOPE WITH MAIL ORDERS
*
Person ordering: Must attach legible photocopy of current, valid ID or legal representative document.
________
Number of certified records requested.
QUANTITY
$25.00 first record / $20.00 each additional of the same record ordered at the same time.
(1) Name of Infant:
First
Middle
Last
(2) Date of Birth: _______________ (3) SEX:
Male
Female
(4) Place of Birth:
MM / DD / YYYY
Hospital / Facility
(5) Mother’s Full Maiden Name: ___________________________________________________________________________________
First
Middle
Maiden Last Name
(6) Father’s Full Name: __________________________________________________________________________________________
First
Middle
Last
(7) Your Relationship to Infant:
Mother
Father
Sibling (18yrs. or older)
Maternal Grandparent
Paternal Grandparent
Legal Guardian
(8) *Name of Person Ordering: ____________________________________________________________________________________
(9) Mailing Address: ___________________________________________________________________________________________
City: _____________________________________ State: ___________________ Zip Code: ____________________
(10) Signature: __________________________________________________ (11) Phone Number: _____________________________
In Accordance with law – ORS 432.120, access to birth records is restricted for 100 years to registrant, family members, legal representatives, government agencies and persons licensed or registered under ORS 703.430. Legal
guardians must enclose a copy of the legal document. If you are not eligible, enclose a written permission note with a notarized signature of an eligible person. Providing false information is a felony under ORS 432.900.
OFFICE USE ONLY. DO NOT WRITE BELOW THIS LINE
OR DL: __________________ Exp. Date: ____________ Pmt Type: Cash / CC / Check-MO# __________________
Passport or Other ID: _______________________________________ Today’s Date: ______________________
Exchange
Returned Cert #s: _____________________ Certificate Number(s):__________________________
Case # :______________ Order #: _________________________________Amount Received: $ ______________
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