Vital Statistics - Health Department
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Today's Date: _________________

Birth Record: __________ Death Record: __________

Number of Copies: _________ ($25.00 each; all are certified copies)

Full Name of Person: ____________________________________________________

Date of Birth or Death: __________________________________________________

Place of Birth or Death: __________________________________________________


Mother's Full Maiden Name (for birth certificates)_________________________________

Father's Full Name (for birth certificates)___________________________________

Your Name: ____________________________________________________________

Address: ______________________________________________________________

City, State, Zip: ________________________________________________________

Phone Number: _________________________________________________________

Method of Payment:
WE DO NOT ACCEPT CASH. PLEASE SELECT A PAYMENT OPTION BELOW.
____ Check (payable to: Mansfield/Ontario/Richland County Health Department)
____ Money Order: # _______________________________
____ Credit Card (MC/Visa only): # _______________________________ Expiration Date _________

Send Completed Application Form and Payment along with a stamped, self-addressed envelope to:

Mansfield/Ontario/Richland County Health Department
Attn: Vital Statistics Division
555 Lexington Avenue
Mansfield, OH 44907

FOR OFFICIAL USE ONLY:

Fee Paid:________________ Receipt #: _____________________________