Vital Records Information  BIRTH:

Name at Birth:

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Date of Birth:

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Age at Birth:

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Father's  Name:

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Mother's Name:

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For What purpose is information required?

__________Family Geneology Research______________

What was you relationship to the person whose record is requester?

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Signature of Applicant:
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Date:
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Address:
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                            Please PRINT name and address where record should be sent:

Name:
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Street:
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City:
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State:
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Zip:
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