CERTIFICATE OF IDENTITY/SWORN STATEMENT - BIRTH, DEATH & PUBLIC MARRIAGE
In accordance with California State Law, the following identifying information is required to obtain a certified copy of Birth,
Death or Public Marriage Certificate. You must be one of the following to receive an authorized copy of a birth, death or
public marriage record, individual named on certificate, parent, child, legal guardian/custodian, grandparents, grandchild,
sibling, spouse/domestic partner, attorney for individual/estate of individual or representative of an adoption agency (birth
only), funeral director or agent/employee (death only).
This certificate must be signed in the presence of a Notary.
Name(s) on Certificate Relationship
I, , declare under penalty of perjury under the laws of the State of
California, that I am an authorized person, as defined in California Health and Safety Code Section 103526(c), and am
eligible to receive a certified copy of the birth or death record for the individual(s) listed above.
Subscribed to the day of 20 , at , .
(Day) (Month) (City) (State)
CERTIFICATE OF ACKNOWLEDGEMENT
STATE OF CALIFORNIA )
County of )
On , before me personally appeared
(Insert name and title of officer here)
DEAN C. LOGAN
COUNTY OF LOS ANGELES
P.O. BOX 489, NORWALK, CALIFORNIA 90651-0489 - www.lavote.net
______________________________________, who proved to me on the basis of satisfactory evidence, to be the person
whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
WITNESS my hand and official seal.
R1995 Rev. 3/2010