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Correction Of Birth Record Application Finding And Order For Correction Of Birth Record 2.0 - Ohio

Correction Of Birth Record Application Finding And Order For Correction Of Birth Record Form. This is a Ohio form and can be used in Birth Records Probate Mahoning County (Court Of Common Pleas) .
 Fillable pdf Last Modified 11/14/2013
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IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY CORRECTION OF BIRTH RECORD APPLICATION, FINDING AND ORDER FOR CORRECTION OF BIRTH RECORD [R.C. ยง3705.15;] CASE NO. ___________________ _______________________, the Applicant, prays that his/her birth record be corrected in accordance with section 3705.15 of the Ohio Revised Code, as follows: Applicant's Full Name (at time of birth) _____________________________________________ [Social Security No._________________ ] Place of Birth ______________________________________________________ Date of Birth ____________________ (City, State, Hospital, Home Address) Applicant's sex at the time of his/her birth: Male Female Father's Full Name _____________________________________________________ Age of Father (at time of birth) ________________ Birthplace of Father _____________________________________________________ Mother's Maiden Name __________________________________________________ Age of Mother (at time of birth) _______________ Birthplace of Mother ________________________________________________________________________________________________ Item(s) to be corrected or added. Item _______________ reads as ____________________________________should read____________________________________ Item _______________ reads as ____________________________________should read____________________________________ (Supplement, if necessary, and attach). Wherefore the undersigned applicant, being first duly sworn, says that the facts stated in the foregoing Application are true as he/she verily believes. ___________________________________________________ Applicant's Signature _____________________________________________________________ Full Address _____________________________________________________________ City, State, Zip Area Code/Phone Sworn to before me and signed in my presence by the applicant aforesaid this ___________day of ____________________, 20 _____. (SEAL) ________________________________________________________ Notary Public JUDGMENT ENTRY The Court, upon consideration of the aforesaid and the evidence submitted, finds that the applicant personally appeared and was examined, that notice of hearing was completed or was dispensed with and Orders that the birth record of applicant be corrected in accordance with the facts hereinabove set forth; and that a certified copy of the Order of the Court be forthwith transmitted to the Director of Health, at Columbus, Ohio, as provided by law. ______________________________________________________ Hon. Mark Belinky, Judge I hereby certify the above is a true copy of the application and entry in the foregoing matter. ________________________________________________________ Hon. Mark Belinky, Judge (SEAL) By ________________________________________________ Deputy Clerk M.C. Form 2.0 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ___________________ The State of ____________, County of __________________________: Affidavit of Physician I, _________________________________________________________, do hereby certify that I was the physician in attendance at the birth of (Typed or Printed Name) _____________________________________________________, the applicant herein, and that the facts in the application are true, as I verily believe. ________________________________________ Signature of Attending Physician ______________________________________________ Address Sworn to before me and signed in my presence this ______________ day of __________________________, 20________. ______________________________________________ (SEAL) ______________________________________________ Notary Public NOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the following affidavits of two persons, relative or nonrelative, having personal knowledge of the facts or by clear and convincing documentary evidence or such other evidence as the Court deems sufficient. The State of ________, County of ___________________: Affidavit of_____________________________________ I, ___________________________________________ (Age_________ Years), do hereby certify that I have personal knowledge of the facts stated (Typed or Printed Name) in the within application by virtue of ____________________________________________ and that the facts stated herein are true, as I verily believe. ________________________________________ Signature of Affiant ______________________________________________ Address Sworn to before me and signed in my presence this ______________ day of __________________________, 20________. ______________________________________________ (SEAL) ____________________________________________ Notary Public The State of ________, County of ____________________: Affidavit of____________________________________ I, ___________________________________________ (Age_________ Years), do hereby certify that I have personal knowledge of the facts stated (Typed or Printed Name) in the within application by virtue of ____________________________________________ and that the facts stated herein are true, as I verily believe. ________________________________________ Signature of Affiant ______________________________________________ Address Sworn to before me and signed in my presence this ______________ day of __________________________, 20________. ______________________________________________ (SEAL) ______________________________________________ Notary Public M.C. Form 2.0 American LegalNet, Inc. www.FormsWorkFlow.com
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