COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH
313 N. FIGUEROA ST. RM L-1, LOS ANGELES, CA 90012 (213) 288-7812
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
(We maintain records of births until the child's first birthday)
Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED Certified Copy of
a birth record.
The registrant or a parent or legal guardian of the registrant
A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency
seeking the birth record in order to comply with the requirements of Section 3140 or 7603 of the Family Code
A member of a law enforcement agency or a representative of another governmental agency, as provided by
law, who is conducting official business.
A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant
An attorney representing the registrant or the registrant's estate, or any person or agency empowered by
statute or appointed by a court to act on behalf of the registrant or the registrant's estate.
I am requesting an A
copy I am requesting an I
AGE LAST BIRTHDAY – EDAD CUMPLIDA NUMBER OF COPIES
NUMERO DE COPIAS
Month/Mes Day/Dia Year/Año
Date of Birth – Fecha De Nacimiento
NAME GIVEN AT BIRTH (first, middle , last) –NOMBRE DE NACIMIENTO (primer, segundo, appellido)
CITY OF BIRTH – CIUDAD DE NACIMENTO
NAME OF FATHER – NOMRE DEL PADRE
MAIDEN NAME OF MOTHER – NOMBRE DE SOLTERA DE LA MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LAS PERSONA REGISTRADA (VEASE ARRIBA)
I ____________________________________ swear (or
affirm) under penalty of perjury that I am an
authorized person, as defined in California Health and Safety Code Section 103525(c), and am eligible
to receive an AUTHORIZED certified copy of the birth record identified on this application form.
Sworn this ______ day of __________________, _________ at ______________________________
STREET ADDRESS/NUMERO Y CALLE
CITY /CIUDAD STATE/ESTADO ZIP/ZONA POSTAL
Those who are not authorized may receive an INFORMATIONAL Certified Copy with the words "INFORMATIONAL, NOT A
VALID DOCUMENT TO E
STABLISH IDENTITY" imprinted across the face of the copy.
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY
Complete your name and mailing address below. -
Escriba abajo su nombre y direccion.