PRINT or TYPE your name and address ... - Lackawanna County

LACKAWANNA COUNTY APPLICATION FOR

BIRTH/DEATH RECORDS (Birth Records available from 1893 ? 1905) (Death Records available from 1878-1905) *** Excludes Births/Deaths that occurred in the City of Scranton***

Signature of Person making the request:______________________________________ Signature required on all requests.

PRINT or TYPE your name and address:

Name:_________________________________________________________________

Relation to person named on the certificate: ___________________________________

Address:______________________________________ City:_____________________

State:__________ Zip:____________ Phone: __________________________________

PRINT or TYPE the information below with regard to the person named on requested certificate.

Number of Copies: _______________

Name at Birth/ Death: _____________________________________________________

Place of Birth/Death: ______________________________________________________

Maiden name of Mother: ___________________________________________________

Full name of Father: _______________________________________________________

Date of Birth/Death: __________________________________ Sex: M____ F _____

IMPORTANT: PLEASE NOTE The fee for Birth and Death Genealogy searches is $ 25.00 per search. All searches are non-refundable.

Please enclose a self-addressed envelope along with a check made payable to the Marriage License Bureau in the applicable amount. Mail requests to:

FRANCES KOVALESKI

Register of Wills Clerk of Orphans' Court The Scranton Electric Building Suite 400

507 Linden Street Scranton, PA 18503

570-963-6702

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