Fillable Printable Application for Birth/Death Certificate - Louisiana

Application for Birth/Death Certificate - Louisiana

APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH CERTIFICATE

Short-Form Birth Certification Card

Long-Form Birth Certificate

Death Certificate

Number of Copies Requested:

$9.00 each

$15.00 each

$7.00 each

SUBTOTAL

Mail orders add $0.50 state charge per transaction

(no coins)

TOTAL FEES DUE

Record Information

Name at Birth/Death

First Middle Last

Date of Birth/Death

Sex

Father's Name

Last Middle First

City of Birth/Death Parish of Birth/Death

MaidenMiddle

Mother's Full Maiden Name before Marriage

First

Relationship to Person Named on the Certificate (must submit copy of photo ID - Front AND Back)

Self

Mother

Father

Child

Grandparent

Grandchild

Sister

Brother Current Spouse

Legal Guardian (with judgement of custody)

Other (specify):

Applicant Information

First Name Last Name

Residence Address City

State

ZIP Code

Day Phone

I am aware that any person who willfully and knowingly makes any false statement on an application for a certified copy of a vital record is

subject upon conviction to a fine of not more than $10,000 or imprisonment of not more than five years, or both.

Name

Address

City

ZIP

Mail completed application to:

Center for Records and Statistics

P.O. Box 60630

New Orleans, LA 70160

Signature

Order will be returned if items not completed

and included:

Signed

application

Copy of Federal or State

photo ID (front AND back)

Correct fees

NOTE: Birth records over 100 years old and Death records over 50 years old can be obtained by writing the Secretary of State.

Address: Louisiana State Archives, P.O. Box 94125, Baton Rouge, LA 70804-9125.

If no record is found, you will be notified

and fees will be retained for the search

per R.S. 40:40

Mailing Address for Certificates

Office Use Only

State

Rev 5/12

ALL MAIL ORDER PAYMENTS MUST BE CHECK OR MONEY ORDER ONLY - Payable to LOUISIANA VITAL RECORDS