Fillable Printable Birth / Death Certificate Mail Order Form - Washington

Birth / Death Certificate Mail Order Form - Washington

Washington State Department of Health

Birth / Death Certificate Mail Order Form

Complete payment and mailing information below:

Total number of certified certificates:

x $20.00 =

Total number of Heirloom

birth certificates:

x $40.00 =

Fee for filing a Paternity Acknowledgment OR an Adoption

$15.00 =

Paternity Verification Letter (copy of parent ID required)

$15.00 =

Paternity Verification Letter ($15) + certified birth certificate ($20)

$35.00 =

First Class Mail (allow 2-3 weeks for delivery)

No additional charge

*USPS Express Mail Delivery (street address or PO Box)

$18.30 =

*Fed Ex to continental US (no PO Box)

$15.00 =

*Fed Ex to AK/HI/Canada/Mexico (no PO Box)

$25.00 =

TOTAL AMOUNT DUE

Instructions

• Print clearly.

• We issue certificates for births and deaths that occurred in Washington State only.

• For a birth or death before July 1, 1907, contact the local health department where the event occurred.

• We only accept checks or money orders for mail orders. Do not send cash or credit card information.

• $20.00 per certificate.

• If adopted, provide your adoptive name and adoptive parents’ information.

• Visit www.doh.wa.gov

for more information and ordering options or call 360-236-4300, Monday through Friday

between 8:00 a.m. and 5:00 p.m. Pacific Time.

Contact

Information

Name of person ordering certificate(s):

Company name (if applicable):

Address sending certificate(s) to:

(Street address required for FedEx orders)

City: State: ZIP Code:

Daytime Phone: (______) ______________________ Email Address:

Complete ALL fields below with exact and complete information.

Paternity Verification Letter (Copy of Parent

ID required). Court activities such as custody,

parenting

plan or child support may require a paternity

verification letter AND a birth certificate.

Birth Certificate Request

Number of Certificates Ordering_____

Full Name on Certificate:

(First) (Full Middle Name) (Last)

Date of Birth (Month/Day/Year):

(7/1/1907 – present)

City or County of Birth:

Father/Parent Birth Name:

(First) (Full Middle Name) (Birth/Maiden Last Name)

Not

Listed

Mother/Parent Birth Name:

(First) (Full Middle Name) (Birth/Maiden Last Name)

Death Certificate Request

Number of Certificates Ordering______

Name on Certificate:

(First) (Middle) (Last)

Approximate Date of Death or 10 year

search range (7/1/1907 – present):

Date of Birth, if known:

City or County of Death: Spouse, if known:

Make checks or

money orders payable

to DOH.

MAIL ORDERS TO:

Department of Health

PO Box 9709

Olympia WA

98507-9709

*Additional charges for express delivery are per order, not per certificate.

*Signature is required at time of delivery for USPS Express Mail and Federal Express orders.

DOH 422-044 November 2014 +Go to our website at www.doh.wa.gov for information on Heirloom Birth Certificates.