Ohio Department of Health Bureau of Vital StatisticsApplication for Certified CopiesCheck appropriate boxBirth Certificate $9.00 eachDo not write in this space AFS No.Death Certificate $9.00 eachVolume No.Paternity Affidavit $7.00 eachCertificate No.IMPORTANT!Intended for Ohio records only. Each copy requested must have the required fee. Enclose check or money order. Must be made payable to Treasurer, State of Ohio , do not send cash. Notice Fee overpayment of $2.00 or less will not be refunded ORC 3705.24To be printed below is information about requested certificate.Full namefirstmiddlelastPhone()Present addressnumber and streetcity, village or townshipstateZIPParentsmother's firstmother's maidenfather's firstfather's lastPlace of eventcountycity, village or townshipDate of eventAge (last birthday)Amount enclosedDate of paymentCashCheckMoney order$To your knowledge has a copy of this record been obtained before?Have any corrections/changes been made to this certificate?YesNoUnknownUnknownNoYesApplicant's signatureDateDo not detach Print name and address of person to whom certificates(s) is (are) to be mailed in the space below. This is a mailing insert and will be used to mail the certified copy which you have requested. When the above application and the name and address in the section below have been completed please send the entire form to the preprinted address below:NameOhio Department of Health Bureau of Vital Statistics P.O. Box 15098 Columbus. Ohio 43215-0098AddressCityZIPStateHEA 2709 (Rev. 8/99)5132.062001 © American LegalNet, Inc.
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