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Request For Copy Of Birth Or Death Certificate - Texas

Request For Copy Of Birth Or Death Certificate Form. This is a Texas form and can be used in General Dallas Local County .
 Fillable pdf Last Modified 4/25/2014
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Office of John F. Warren County Clerk Dallas County, Texas Records Building 509 Main St Ste 200 Dallas, Texas 75202 (214) 653 - 7477 Certified copy of Birth or Death Certificate Information Qualified Applicants Birth records are confidential for 75 years. Death records are confidential for 25 years. Qualified Applicants that may submit a request for a Birth/Death Certificate (must have valid state issued ID or Driver's License): · · · · Self Spouse Grandparent Parent · · · Child Sibling Legal Representative (Must have a certified copy) The Dallas County Clerk office only provides the long form birth certificate and death certificates that occurred in Dallas County excluding the City of Dallas. Long Form Birth Certificates and Death Certificates AVAILIBLE for the following Cities Addison Balch Springs Carrollton Cedar Hill Cockrell Hill Coppell Desoto Duncanville Farmers Branch Garland Glenn Heights Grand Prairie Highland Park Hutchins Irving Lancaster Las Colinas Mesquite Richardson Rowlett Sachse Seagoville Sunnyvale University Park Wilmer/Wylie Please visit www.DallasCounty.org for more information Long Forms NOT AVAILIBLE for the following hospitals Baylor University Medical Center * 3500 Gaston Ave Charlton Methodist Hospital * 3500 W. Wheatland Rd Children's Medical Center of Dallas * 1935 Motor St Dallas Veterans Affairs Medical Center 4500 S. Lancaster Doctors Hospital * 9330 Poppy Drive Green Oaks Psychiatric Hospital * 7808 Clouds Fields LifeCare Hospital of Dallas * 6161 Harry Hines Mary Shiels Hospital * 3515 Howell St. Medical City Children's Hospital * 7777 Forest Lane Medical City Dallas * 7777 Forest Lane Methodist Medical Center * 1441 N. Beckley Avenue Parkland Memorial Hospital * 5201 Harry Hines Presbyterian Hospital of Dallas * 8200 Walnut Hill Renaissance Hospital Dallas * 2929 S. Hampton Rd St. Paul Medical Center * 5909 Harry Hines Texas Scottish Rite Hospital for Children * 2222 Welborn Processing Times Routine processing may take up to 2 weeks. Expedite your service by mailing your request by Express Mail. You may also provide an enclosed paid envelope. Expedited processing may take up to 2-3 business days. Visit www.Texas.Gov or www.DallasCityHall.com for more information Mail the following Items 1. Form 2. Copy of ID 3. Money Order Payable to: Dallas County Clerk 4. Optional: Self Addressed Pre-postage Envelope (Printed no more than 60 days) Mailing Address Dallas County Clerk's Office ATTN: Birth/Death Certificate 509 Main St Suite #200 Dallas, TX 75202 American LegalNet, Inc. www.FormsWorkFlow.com Office of John F. Warren County Clerk Dallas County, Texas Request for certified copy of Dallas County Birth or Death Certificate Type of Request Please select the document(s) for which you are applying Birth Death Type # of Copies Cost Total Type # of Copies Cost Total Abstract Long Form* *View list on front for availability $23 each $23 Each Total Cost $ $ $ Original* Additional Copies *View list on front for availability $21 (1st copy) $4 each Total Cost $ $ $ RECORD INFORMATION (Information de certificado ) Name on Record: (Nombre) Date of Birth: (Nacimiento) Place of Birth/Death: (Lugar) Hospital Name: (Hospital) Fathers Name: (Padre) Mothers Name: (Madre) First name/Primer nombre Middle/Segundo Date of Death Last Name/Appellido Month/Mes Day/Dia Year/Año (Desfuncion dia) Month/Mes Day/Dia Year/Año City or Town/ Cuidad de naciamento County/Condado de naciamento State/Estado de naciamento Hospital Name/Nombre de hospital We do not offer Birth/Death Certificates for the City of Dallas No ofrecemos actas de nacimiento/desfuncion para la cuidad de Dallas First/Primer Anterior Middle/Segundo Anterior Last Name/Apellido First/Primer Anterior Middle/Segundo Anterior Last Name/Apellido Anterior REQUESTOR'S INFORMATION (Information de solicitante) Relationship to above: Name: (Nombre) Home address: (Domicilio) Phone #: (Telefono) (Self, Mother of , Father of, Sister of, Brother of, Daughter of, Son of, Grandparent of, etc) First/Primer Middle/Segundo Last Name/Appellido # Street/Calle Apt # City/Ciudad (For Receipt) State/Estado Zip Code/Codigo ( ) First/Primer E-mail: @ Middle/Segundo Last/Apellido Mailing address (if different) (Lugar de correo) Name of person receiving mail (if different): (Persona recibiendo documento) # Street/Calle Apt # City/Ciudad State/Estado Zip Code/Codigo X Requestor's Signature Date: (Must sign to process) Check Driver's License Passport Other Identifying Documents (include copy) Date Issued Expiration Date Place of Issue Receipt # Security # WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC 195.003) Office use only Issuing Clerk Location Year Volume Page American LegalNet, Inc. www.FormsWorkFlow.com Amount Received Form revised 09/27/2013 DCCYWOT
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