APPLICATION FOR BIRTH RECORD
**16-37-1-8 Indiana Vital Statistics law requires a Health Officer may only issue a certified copy
if he/she is satisfied by the applicant's direct interest in the record.
Name of Applicant
Address
City
State
Zip Code
Phone #
Email
Relationship to Record Requested
**Proof of relationship may be required for issuance
Please call 765-747-7721 ex. 752, 750 or 765 for questions on validating documents.
ADOPTION (circle one) YES or NO
LEGAL CHANGES OR COURT ORDERS (circle one) YES or NO
NAME
NAME AFTER LEGAL CHANGES
DATE OF BIRTH
GENDER (Circle One) MALE or FEMALE
Did the birth occur in Delaware County? (circle one) YES or NO if not, what county
FATHER'S NAME
STATE OF FATHER'S BIRTH
MOTHER'S NAME
STATE OF MOTHER'S BIRTH
MOTHER'S MAIDEN NAME
Certified Birth Certificates are $20 for each copy, payable by money order or cashier's check.
Number of copies requested
x $20
Uncertified Genealogical Copies are $10
Number of copies requested
x $10
Total Amount Remitted: $
The following items MUST be submitted with your request to avoid delays
- Photo copy of *CURRENT PICTURE ID
- * PAYMENT: Money order or cashier's check (no personal checks)
- * SELF ADDRESSED STAMPED ENVELOPE.
- * ANY SUPPORTING DOCUMENTATION OF PROOF OF RELATIONSHIP
Signature
Date
Office use only: ID#
Searched By
Date