Vital Statistics - Health Department
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Today's Date: _________________ Is this a Birth Certificate for a Passport? ___ YES ___ NO

Birth Record: __________ Death Record: __________

Number of Copies: _________ ($20.00 each; all are certified copies)

Full Name of Person: ____________________________________________________

Date of Birth or Death: __________________________________________________

Place of Birth or Death: __________________________________________________

REMEMBER: For births or deaths since 1968 in Shelby, contact the City of Shelby (419-347-5131)

Your Name: ____________________________________________________________

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

Father's Full Name (for birth certificates)

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: # _______________________________ 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 #: _____________________________