MARION PUBLIC HEALTH APPLICATION FOR CERTIFIED COPIES RECORD INFORMATION: (Information about the person you are requesting the record for) Full name on birth or death certificate: If name was changed birth, indicate new name: (i.e. adoption, legal name change, Middle Maiden/Last paternity, etc.) Date of and/or Date of Death: City and County where event occurred: Full First Full Middle Maiden/Last Name Full First Full Middle Maiden/ Last Name OMother OMother OFather O Father OParent OParent CHARGES: $ 25.00 PER COPY If you do not need a birth certificate for any of the following reasons, skip this Number of copies requested: Birth: section. Otherwise please indicate what the certificate is needed for: Dual Citizenship o Genealogy x $25.00 = $ Out of Country Marriage o International Legal Business All death certificates will be issued without a social security number unless identification is provided confirming you are one of the below listed authorized requestors: The deceased's spouse or descendent Number of copies requested: The deceased's executor, attorney, or legal agent A representative of investigative government agency x $25.00 = $ Death: A private investigator A funeral director (or agent responsible for disposition of the body) acting on behalf of the deceased's family A veteran's service office An accredited member of the media You must attach a copy of your identification showing you are an authorized requestor along with a copy of a valid driver's license. Number of fetal death record Death: copies requested: x 25.00 = $ Total Amount Due: $ PURCHASER'S 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. Purchaser's Email: Name: Street Address: Phone Number: City, & ZIP: Signature: MAILING ADDRESS: Send completed application with required fee to: Marion Public Health 181 South Main Street Marion, Ohio
MARION PUBLIC HEALTH APPLICATION FOR CERTIFIED COPIES RECORD INFORMATION: (Information about the person you are requesting the record for) Full name on birth or death certificate: Middle Maiden/Last If name was changed birth, indicate new name: (i.e. adoption, legal name change, paternity, etc.) Date of and/or Date of Death: City and County where event occurred: OMother OFather OParent Full First Full Middle Maiden/Last Name OMother O Father OParent Full First Full Middle Maiden/ Last Name CHARGES: $ 25.00 PER COPY Birth: If you do not need a birth certificate for any of the following reasons, skip this section. Otherwise please indicate what the certificate is needed for: Dual Citizenship o Genealogy Out of Country Marriage o International Legal Business Number of copies requested: x $25.00 = $ Death: All death certificates will be issued without a social security number unless identification is provided confirming you are one of the below listed authorized requestors: The deceased's spouse or descendent The deceased's executor, attorney, or legal agent A representative of investigative government agency A private investigator A funeral director (or agent responsible for disposition of the body) acting on behalf of the deceased's family A veteran's service office An accredited member of the media You must attach a copy of your identification showing you are an authorized requestor along with a copy of a valid driver's license. Number of copies requested: x $25.00 = $ Death: Number of fetal death record copies requested: x 25.00 = $ Total Amount Due: $ PURCHASER'S 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. Purchaser's Name: Email: Street Address: Phone Number: City, & ZIP: Signature: MAILING ADDRESS: Send completed application with required fee to: Marion Public Health 181 South Main Street Marion, Ohio
2018-Vitals-Application.docx