Application For Certified Copies {HEA 2709}

OhioDepartmentofHealth·OfficeofVitalStatistics Application For Certified Copies Reason for order Driver's License Insurance School Marriage License Passport Genealogy International Use 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 office use only Order Number (AFS) Service Certificate Number Certificate Requested: (What type of certificate is being ordered) Birth Certificate $21.50 per certificate Death Certificate $21.50 per certified copy Heirloom Birth Certificate $25.00 per commemorative certificate Fetal Death Certificate $21.50 per certified copy Paternity Affidavit $7.00 per certified 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 first marriage): Have there been any corrections or legal changes made to the information on this certificate? 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): Total number of heirloom commemorative birth certificates: Total number of paternity affidavits: Refunds will be issued only for orders where a certified document cannot be issued, and may be subject to search fees. Overpayment of $2.00 or less will not be refunded. X $21.50 = X $25.00 = X $7.00 = $ $ $ $ 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: Street Address: City, State, & ZIP: Email: Phone Number: Signature of Applicant: HEA 2709 (Rev. 06/11) American LegalNet, Inc. www.FormsWorkFlow.com