Fillable Printable Application For Certified Copies - Ohio

Application For Certified Copies - Ohio

 OhioDepartmentofHealth•OceofVitalStatistics

Application For Certied Copies

Reason for order

Driver’s License Passport

Insurance Genealogy

School International Use

Marriage License Other

Mail-in order

Send completed application with required fee to:

Ohio Department of Health,

Vital Statistics

P.O. Box 15098

Columbus, Ohio 43215-0098

(614) 466-2531

This space for oce use only

Order Number (AFS)

Service

Certicate Number

Certicate Requested: (What type of certicate is being ordered)

Birth Certicate

$21.50 per certicate

Heirloom Birth Certicate

$25.00 per commemorative certicate

Paternity Adavit

$7.00 per certied copy

Death Certicate

$21.50 per certied copy

Fetal Death Certicate

$21.50 per certied copy

Stillbirth Commemorative Abstract

Free to birth parents for stillbirth events

taking place after September 26, 2003

Registrant Information: (Information about the person on the requested record)

Full name (for birth, indicate child’s full name as shown on original birth record): Date of birth:

Place of birth/death (City/County in Ohio): Date of death: CPR stamp number (Paternity only):

Full name of father: Full name of mother (maiden name prior to rst marriage):

Have there been any corrections or legal

changes made to the information on this

certicate?

c Yes c No

If name was changed since birth, indicate

new name:

Did the stillbirth event occur after 20

weeks or less gestation?

(Fetal Death/Stillbirth only)

c Yes c No

Charges: Please include check or money order (do not send cash) made payable to “TREASURER, STATE OF OHIO”

Total number of standard copies or abstracts (birth, death, fetal death): X $21.50 = $

Total number of heirloom commemorative birth certicates: X $25.00 = $

Total number of paternity adavits: X $7.00 = $

Refunds will be issued only for orders where a certied document cannot be issued,

and may be subject to search fees. Overpayment of $2.00 or less will not be refunded. TOTAL AMOUNT DUE: $

Applicant Information: (Information about the person requesting the record)

Please print clearly as this will be used for your receipt, mailing address, and/or for future contact to complete your record request.

Applicant Name: Email:

Street Address:

Phone Number:

City, State, & ZIP:

Signature of Applicant:

HEA 2709 (Rev. 06/11)