Fillable Printable Application for Certified Copy of Certificate of Birth - Tennessee

Application for Certified Copy of Certificate of Birth - Tennessee

TENNESSEE DEPARTMENT OF HEALTH

OFFICE OF VITAL RECORDS

APPLICATION FOR CERTIFIED COPY OF CERTIFICATE OF BIRTH

(La versión en español al reverso de la página)

Date:

Full name on birth certificate:

First Middle Last Name

Has the name ever been changed o t her than by marriage? Yes No

If yes, what was original name?

Date of birth: Sex:

Male or Female

Month Day Year

Place of birth :

City County State

Hospital where birth occurred:

Full name of father:

Full maiden name of mother:

Last name of mother at time of birth:

Next older brother or sister:

Younger:

Signature of person making request:

Relationship:

Purpose of copy:

Telephone number wh ere you may be reached for additional information:

( )

IT IS UNLAWFUL TO WILLFULLY AND KNOWINGLY MAKE ANY FALSE STATEMENT ON THIS APPLICATION.

All items must be completed and appropriate fees attached to process this request. Do not send cash. Send check or money order

payable to: Tennessee Vital Records. In addition, unless this application is notarized, you must send a photocopy of a

government issued ID showing your signature. If you have not received a response within 45 days, please write or call Tennessee

Vital Records at (615) 741-1763.

PH-1654 (rev 11/2008) RDA N/A

FILL OUT BELOW/ DO NOT DETACH

PRINT name and address of person to whom the certified copy is to be mailed. SEND TO:

Name

Address o r Route

City and State Zip Code

Tennessee Vital Records

421 5

Avenue North

floor, Central Services Building

Nashville, TN 37243

Indicate number of each type

of certificate desired and

enclose appropriate fee:

For years 1949-Current:

___ Short form- $8.00

first

copy. Additional copies

of same record

purchased at same time-

$5.00 each.

___ Long form- $15.00

first

copy. Additional Copies

of same record

purchased at the same

time-$5.00 each.

For births before 1949

No short form available

___ $15.00

first copy.

Additional copies of

same record purchased

at the same time -$5.00

each.

The above fees are charged

for the search of records and

will not be refunded even if no

record is on file in this office.

A 3-year search is provided

for the initial fee.