REG-2, Delegation of Authority to Receive Certified Copy ...
New Jersey Department of HealthOffice of Vital Statistics and RegistryP.O. Box 370Trenton, NJ 08625-0370DELEGATION OF AUTHORITY TO RECEIVE CERTIFIED COPY OF VITAL RECORD(FOR BIRTH / DEATH RECORDS)Delegación de autoridad para recibir una copia certificada de un registro civil(PARA REGISTROS DE NACIMIENTO / MUERTE)This statement must be signed and dated in the presence of a Notary Public. Authorized individual must also provide valid identification.Este documento debe ser firmado y fechado ante un notario público. El individuo autorizado también debe proveer prueba de identificación valida.Full Name of Authorizing Person(Nombre Completo de la Personal Autorizante) FORMTEXT ?????Relationship to Individual on Record(Relación con el Individuo en Registro) FORMTEXT ?????I give written authorization to: (Yo otorgo autorizacion por escrito a:)Name of Authorized Individual(Nombre de Individuo Autorizado) FORMTEXT ?????who will obtain certified copies of vital records on my behalf. The information of the requested record is as follows:(quien obtendrá copias certificadas del registro civil en mi nombre. La información del registro is la siguiente:)Name on Record (Nombre en Registro)First (Primer)Middle (Segundo)Last (Apellido) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Exact Date of Event (MM/DD/YYYY)(Fecha Exacta del Evento) (Mes/Día/A?o) FORMTEXT ?????Location of Event (City and County)(Lugar del Evento) (Ciudad y Condado) FORMTEXT ?????Full Name of Parent A (List name given at birth or on birth certificate/Maiden name) [Nombre completo de Padre/Madre A (Inscrito en el acta de nacimiento o nombre de soltera)]First (Primer)Middle (Segundo)Last (Apellido) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Full Name of Parent B (List name given at birth or on birth certificate/Maiden name) [Nombre completo de Padre/Madre B (Inscrito en el acta de nacimiento o nombre de soltera)]First (Primer)Middle (Segundo)Last (Apellido) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature of Authorizing Person(Firma de la Personal Autorizante)Date(Fecha) FORMTEXT ?????Sworn to before me on this ________________ day of ____________________________, 20______.Signature of Notary Public: _______________________________________________________________________________________________(Stamp) ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- the official web site for the state of new jersey
- instructions for completing items on the
- reg 2 delegation of authority to receive certified copy
- 336 john street south amboy nj 08879
- the college of new jersey
- imm 26 the official web site for the state of new jersey
- new provider enrollment package a adult
- reg 68 request to place on file a certificate of birth
Related searches
- reg z right of offset
- how to receive dividend checks
- application for a certified copy of title
- free number to receive sms
- free phone number to receive text
- temporary online phone number to receive sms
- certified copy of birth certificate florida
- certified copy of divorce decree california
- certified copy of divorce decree
- apply for certified copy of birth certificate
- original or certified copy of marriage certificate
- certified copy of divorce records