COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF …
Part I: TO IDENTIFY ORIGINAL BIRTH RECORD . 1. Name of Child BEFORE adoption: * 2. Name of BIOLOGICAL father: * 3. Maiden name of BIOLOGICAL mother: * COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH . VITAL RECORDS . CERTIFICATE OF ADOPTION . PART II: 4. PLACE OF BIRTH (a) City, Borough or Township: ................
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