Form VS-142.3(A) "Application for Birth or Death Certificate" - Jefferson County, Texas

Form form vs-142.3(a) is a County Clerk - Jefferson County, Texas form also known as the "Form Vs-142.3(a) "application For Birth Or Death Certificate" - Jefferson County, Texas". The latest edition of the form was released in September 1, 2015 and is available for digital filing.

Download a PDF version of the Form form vs-142.3(a) down below or find it on County Clerk - Jefferson County, Texas Forms website.

ADVERTISEMENT

Download Form VS-142.3(A) "Application for Birth or Death Certificate" - Jefferson County, Texas

1351 times
Rate
(4.7 / 5) 81 votes
P. O. Box 1151 
Carolyn L. Guidry 
     Phone: 409.835.8475 Option 1 
Beaumont, TX 77704‐1151 
Jefferson County Clerk 
Fax : 409.839.2394 
 
APPLICATION FOR BIRTH OR DEATH CERTIFICATE 
Birth Certificate 
 
 
 
 
 
 
Death Certificate 
____ No. of Certified Copies Requested   
 
 
 
____ No. of Certified Copies Requested 
@$23.00 each = __________________ 
 
 
 
@$21.00 for First Copy and $4.00 additional   
 
 
 
 
copies of same record/same request 
□ 
Applicant wishes to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visiting Program 
administered by the Office of Early Childhood Coordination of the Health & Human Services Commission. 
First Name 
Middle Name 
Last name 
1. Full Name of Person on 
Record: 
 
2. Date of Birth or Death: 
MM/DD/YYYY 
3. Sex: 
Male or Female 
 
4. Place of Birth or Death: 
City or Town 
County 
State 
 
First Name 
Middle Name 
Last Name 
5. Full Name of Father: 
 
First Name 
Middle Name 
Last Name (Maiden) 
6. Full Maiden Name of 
Mother: 
 
First Name 
Middle name 
Last Name 
7. Applicant’s Name 
(Give YOUR Full Name): 
Home phone 
Cell phone 
 
8. Applicant’s Telephone 
Number: 
Street Address 
City 
State 
Zip code 
9. Mailing Address: 
 
 
 
10. Relationship to Person 
 
Named in Item No. 1: 
11. Purpose for Obtaining 
 
this Record: 
12. Additional Identifying 
Decedent’s SSN 
Decedent’s Birth Date 
Decedent’s Birth Place 
Information for Death 
Certificate: 
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2‐10 YEARS 
IN PRISON AND A FINE OF UP TO $10,000 (HEALTH & SAFETY CODE, CHAPTER 195, SEC. 195.003) 
 
 
__________________________________ 
 
______________________________________________ 
Date of Application 
 
 
 
 
Applicant’s Signature 
If requesting by mail or Fax, Applicant must attach copy of Driver’s License or State Issued Identification. 
 
Office Use Only 
 
Certificate No. :__________________   
 
Document Control No.: ___________________________ 
 
Form of I.D. :____________________   
 
Number on D.L. or I.D.: ___________________________ 
Effective Date of Form:  January 1, 2014 
P. O. Box 1151 
Carolyn L. Guidry 
     Phone: 409.835.8475 Option 1 
Beaumont, TX 77704‐1151 
Jefferson County Clerk 
Fax : 409.839.2394 
 
APPLICATION FOR BIRTH OR DEATH CERTIFICATE 
Birth Certificate 
 
 
 
 
 
 
Death Certificate 
____ No. of Certified Copies Requested   
 
 
 
____ No. of Certified Copies Requested 
@$23.00 each = __________________ 
 
 
 
@$21.00 for First Copy and $4.00 additional   
 
 
 
 
copies of same record/same request 
□ 
Applicant wishes to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visiting Program 
administered by the Office of Early Childhood Coordination of the Health & Human Services Commission. 
First Name 
Middle Name 
Last name 
1. Full Name of Person on 
Record: 
 
2. Date of Birth or Death: 
MM/DD/YYYY 
3. Sex: 
Male or Female 
 
4. Place of Birth or Death: 
City or Town 
County 
State 
 
First Name 
Middle Name 
Last Name 
5. Full Name of Father: 
 
First Name 
Middle Name 
Last Name (Maiden) 
6. Full Maiden Name of 
Mother: 
 
First Name 
Middle name 
Last Name 
7. Applicant’s Name 
(Give YOUR Full Name): 
Home phone 
Cell phone 
 
8. Applicant’s Telephone 
Number: 
Street Address 
City 
State 
Zip code 
9. Mailing Address: 
 
 
 
10. Relationship to Person 
 
Named in Item No. 1: 
11. Purpose for Obtaining 
 
this Record: 
12. Additional Identifying 
Decedent’s SSN 
Decedent’s Birth Date 
Decedent’s Birth Place 
Information for Death 
Certificate: 
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2‐10 YEARS 
IN PRISON AND A FINE OF UP TO $10,000 (HEALTH & SAFETY CODE, CHAPTER 195, SEC. 195.003) 
 
 
__________________________________ 
 
______________________________________________ 
Date of Application 
 
 
 
 
Applicant’s Signature 
If requesting by mail or Fax, Applicant must attach copy of Driver’s License or State Issued Identification. 
 
Office Use Only 
 
Certificate No. :__________________   
 
Document Control No.: ___________________________ 
 
Form of I.D. :____________________   
 
Number on D.L. or I.D.: ___________________________ 
Effective Date of Form:  January 1, 2014 
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
DATE OF BIRTH/DEATH
FULL NAME OF PERSON ON RECORD
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.
TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
NAME AND RELATIONSHIP TO PERSON ON RECORD
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)
__________________
(Address)
(City)
(State)
who is related
___
(Relationship)
the contents of this affidavit are true and correct.
Signature ____________________________________________________________
Sworn to and subscribed before me, this ________ day of ______________________, 20 ______.
Signature of Notary Public
Commission Expires
(Seal)
Typed or Printed Name
Street Address
City, State and Zip
WARNING: IT IS 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, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Jefferson County Clerk, P.O. Box 1151, Beaumont, TX 77704-1151
(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
Page 2 of 2
VS-142.3(A) Rev. 09/2015
ADVERTISEMENT
Page of 2