Transcription of APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH …
1 APPLICATION FOR CERTIFIED copy OF BIRTH/DEATH CERTIFICATEB irth CertificateBirth Certificate + Birth Card (sold as pair only)Death CertificateNumber of copies Requested:Number of Pairs Requested:Number of copies Requested:$ each$ $ eachSUBTOTALMail orders add $ state charge per transaction (no coins)TOTAL FEES DUE Record InformationName at Birth/DeathFirstMiddle Last Date of Birth/DeathSexFather's Name Last Middle FirstCity of Birth/DeathParish of Birth/DeathMaidenMiddle Mother's Full Maiden Name before MarriageFirstRelationship to Person Named on the Certificate (must submit photo ID)SelfMotherFatherChildGrandparentGrand childSisterBrotherCurrent SpouseLegal Guardian (with judgement of custody)Other (specify).
2 Applicant InformationFirst NameLast NameResidence AddressCityStateZIP CodeDay PhoneEmailI am aware that any person who willfully and knowingly makes any false statement on an APPLICATION for a CERTIFIED copy of a vital record is subject upon conviction to a fine of not more than $10,000 or imprisonment of not more than five years, or both. NameAddressCityZIPMail completed APPLICATION to: Bureau of Vital Records and Statistics Box 60630 New Orleans, LA 70160 SignatureOrder will be returned if items not completed and included:Signed applicationCopy of Federal or State photo IDCorrect fees NOTE: Birth records over 100 years old and Death records over 50 years old can be obtained by writing the Secretary of State.
3 Address: Louisiana State Archives, Box 94125, Baton Rouge, LA no record is found, you will be notified and fees will be retained for the search per 40:40 Mailing Address for CertificatesOffice Use OnlyStateVR Form S1 Rev 7/16 ALL MAIL ORDER PAYMENTS MUST BE CHECK OR MONEY ORDER ONLY - Payable to LOUISIANA VITAL RECORDSC heck for Fetal Death (stillborn) CertificateBureau of Vital Records and Statistics
