APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH CERTIFICATE
Birth Certificate
Birth Certificate
+ Birth Card (sold as pair only)
Death Certificate
Number of Copies Requested:
Number of Pairs Requested:
Number of Copies Requested:
$34.00 each
$48.00
$26.00 each
SUBTOTAL
TOTAL FEES DUE
Record Information
Name at Birth/Death
First Middle Last
Date of Birth/Death
Sex
Father's Name
Last Middle First
City of Birth/Death Parish of Birth/Death
Maiden
Middle
Mother's Full Maiden Name before Marriage
First
Relationship to Person Named on the Certificate (must submit photo ID)
Self
Mother
Father
Child
Grandparent
Grandchild
Sister
Brother Current Spouse
Legal Guardian (with judgement of custody)
Other (specify):
Applicant Information
First Name Last Name
Residence Address City
State
ZIP Code
Day Phone
Email
I am aware that any person who willfully and knowingly makes any false statement on an application for a certified copy of a vital record is
subject upon conviction to a fine of not more than $10,000 or imprisonment of not more than five years, or both.
Signature
Order will be returned if items not completed
and included:
Signed
application
Copy of Federal or
State photo ID
Correct fees
NOTE: Birth records over 100 years old and Death records over 50 years old can be obtained by writing the Secretary of State.
Address: Louisiana State Archives, P.O. Box 94125, Baton Rouge, LA 70804-9125.
If no record is found, you will be notified and fees will be retained for the search per R.S. 40:40. All fees set by statute per R.S. 40:39-40.
Office Use Only
VR Form S1 Rev 6/16
Louisiana Clerk of Court
