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BIRTH $32 each DEATH $24 each FETAL DEATH

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Application for a Vital Record
Office of Vital Records
200 W. Santa Ana Blvd., Suite 100-B, Santa Ana, CA 92701
Allow 10 business days after the birth or death event for record registration and availability.
If no record is found, Health and Safety Code (HSC) 103650 requires our office to retain the fee and issue a Certificate of No Public Record.
FOR MAIL REQUESTS: A SELF-ADDRESSED, STAMPED ENVELOPE AND A NOTARIZED SWORN STATEMENT ARE REQUIRED (Notarized sworn statement is n
ot
required for funeral establishments or government agencies).
Make checks payable to the Orange County Health Care Agency (OCHCA)
1. TYPE OF VITAL RECORD (check one)
BIRTH $32 each DEATH $24 each FETAL DEATH $21 each
2. INFORMATION TO LOCATE RECORD (complete ALL fields)
First Name
Middle Name
Last Name
Date the event occurred (Date of Birth or Death)
City of Occurrence (City of Birth or Death)
Mother’s Maiden Name
3. TO RECEIVE AN AUTHORIZED CERTIFIED COPY, I AM (check one) (Health and Safety Code 103526)
□ Registrant (Name on Certificate)
□ Parent/Legal Guardian of Registrant (Legal guardian must provide
documentation)
□ Child/Sibling of Registrant
□ Spouse/Registered Domestic Partner of Registrant
□ Grandparent/Grandchild of Registrant
□ Authorized by Court Order (Include copy of court order)
□ Law Enforcement/Govt. Agency (Conducting Official Business)
□
Attorney/Licensed Adoption Agency (Under CA Family Code 3140 or 7603)
□ Attorney Representing Registrant or Registrant’s Estate
□ Power of Attorney/Executor of the Registrant’s Estate (Include a copy of
the power of attorney or supporting documentation identifying you as
executor)
□ Agent or Employee of a Funeral Establishment (Acting within the scope of
employment and on behalf of persons specified in HSC 7100 (a) (1)-(8))
□ Surviving Next of Kin as specified in HSC 7100 (ONLY FOR DEATH
CERTIFICATES)
□
None of the above apply; I understand that I will receive an INFORMATIONAL Certificate.
4. CUSTOMER INFORMATION
Name of person requesting certificate
Address Apt/Unit/Suite
Certificates will be picked up by funeral establishment employee
City
State Zip Code
Apt/Unit/Suite
Phone
City
State
Zip Code
5. CERTIFIED COPIES
Registration Number LRN (Not the EDRS Number)
Number of Certified Copies requesting:
Has the Record been Amended (corrected/changed)? YES NO
Causes Pending Investigation, issue: Pending With Final Causes
6. SWORN STATEMENT OF CUSTOMER
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 record for
the registrant identified on this application.
Signature
Date
FOR COUNTY USE ONLY
Amount received $ _____________
Cash Check M/O Credit
Date:
LRN:
Processed by:
BN Paper #
Verified by:
Customer Received
_________# Issued $ __________ in Change ____________Initials
Funeral Establishment Pick-up
______________________ Initials ________________________ Date
Rev 01/2022
COMPLETE ONLY FOR APPLI
CATIONS SUBMITTED BY MAIL
SWORN STATEMENT
I, ___________________________________, declare under penalty of perjury under the laws of the State of California that I am an
(Applicant’s Printed Name)
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 of the following individual(s):
Name of Person Listed on Certificate
Applicant’s Relationship to person Listed on Certificate
(Must Be a Relationship Listed on Page 1 of Application)
(The remaining information must be completed in the presence of a Notary Public.)
Subscribed to this ____________ day of ____________________, 20_________, at __________________________, ______________.
(Day) (Month) (City) (State)
_______________________________________________________________
(Applicant’s Signature)
NOTE: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgement.
A Notary Public must complete the Certificate of Acknowledgment. Only one notarized statement is required per order. (Law
enforcement, local and state government agencies, and funeral representatives are exempt from the notary requirement.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
State of )
County of )
On , before me, ,
(Insert name and title of the officer)
personally appeared ,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) 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 correct.
WITNESS my hand and offic
ial seal.
(SEAL)
___________________________________________________
SIGNATURE OF NOTARY PUBLIC
(R 01/2022) Page 2 of 2
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
Office of Vital Records
200 W. Santa Ana Blvd., Suite 100-B, Santa Ana, CA 92701
AVAILABILITY OF RECORD
• Allow 10 business days after the birth or death event for the record registration and availability for purchase.
• Please note: Per Health and Safety Code 103650, if no record is found during a search for the record, the fee
will be retained and a Certificate of No Public Record will be issued.
• Birth or death certificates are also available for purchase at the County of Orange Clerk-Recorder’s Office after
30 days of a birth or death. If the birth or death took place more than two years ago, the record should be
purchased at the County of Orange Clerk-Recorder’s Office. For more information, visit www.ocrecorder.com
.
COMPLETING THE FORM
Section 1: Type of Vital Record
• Check the box of the type of vital record being requested.
Section 2: Information to Locate the Record
• Enter the information of the person listed on the vital record being requested.
Section 3: Authorized Certified Copy or Informational Certified Copy
• Check the box that applies to you to determine whether you can obtain an Authorized Certified Copy or
Informational Certified Copy of the vital record. Per Health and Safety Code 103526, an Authorized Certified
Copy of vital record can only be obtained by the individual named on the record, the parents of the individual
named on the record and certain other individuals or entities specified by law. All other requestors can only
obtain Informational Certified Copies which cannot be used to establish identity.
• If this section is not completed, the application will be returned.
Section 4: Customer Information
• Enter the information of the person requesting the record.
Section 5: Certified Copies
• Enter the number of copies you are requesting.
• Check the box that applies to acknowledge if record has been amended (corrected or changed).
Section 6: Sworn Statement
The customer req
uesting the record, must sign the sworn statement declaring under penalty of perjury that they
are eligible to receive an Authorized Certified Copy of the vital record as identified in Section 3 of the application. If
mailing the application, a notarized sworn statement is required.
MAIL-IN APPLICATIONS
• If you are applying for a record via mail, a notarized sworn statement is required with your application.
• Please include a stamped, self-addressed envelope with your application.
• We only accept checks or money orders through the mail. Do not send cash. Make checks payable to: Orange
County Health Care Agency (OCHCA)
• Mail application to:
Office of Vital Records
200 W. Santa Ana Blvd., Suite 100-B
Santa Ana, CA 92701
AUTHENTICATION BY APOSTILLE OR CERTIFICATION
• The California Secretary of State provides authentication of public official signatures on documents to be used
outside the United States of America. The country of destination determines whether the authentication is an
Apostille or Certification. If you are seeking a Birth Certificate for use in a foreign country, please obtain a
certified copy from the Orange County Clerk-Recorder's Office (www.ocrecorder.com
) to avoid the extra fee for
authentication.
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BIRTH $32 each DEATH $24 each FETAL DEATH

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Completed 18 March 2022

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