FUNERAL HOMES - Solano County, California
BIRTH CERTIFICATE REQUEST FORM
No. of copies requested:_______($30.00 each)
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|BABY’S NAME: _____________________________________________________________________________ |
|First Middle Last |
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|Date of Birth: ________ Gender: ( ) Female ( ) Male Relationship to the BABY: ________________________ |
|APPLICANT INFORMATION |
|SWORN STATEMENT |
| |
|I, ___________________________________________________, swear under penalty of |
|Print Applicant’s First Name and Last Name. |
| |
|perjury under laws of the State of California, that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to|
|receive a certified copy of the birth record identified on this application form. |
| |
|Sworn this _________ day of _______________, 20 _____, at _________________ , ________________ |
|DATE MONTH YEAR CITY STATE |
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|Mailing Address: __________________________________________________________________________________ |
|Street City State Zip Code |
| |
|PHONE # REQUIRED: (______)_____________________ Signature:______________________________ |
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|We will call you back at this phone number to collect payment. We accept major credit cards. |
|CERTIFICATE OF ACKNOWLEDGMENT |
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|State of ____________________) County of ___________________) On ________________ |
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|before me, _________________________________, personally appeared________________________________________ |
|(name and title of the officer) (Name of Applicant) |
| |
|who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that |
|he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon |
|behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing |
|paragraph is true and correct. |
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|WITNESS my hand and official seal. |
|(SEAL) |
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|_______________________________________________________ |
|SIGNATURE |
| |
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