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DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
AMENDING OR CORRECTING A BIRTH OR DEATH CERTIFICATE
Thank you for submitting your request to amend or correct a birth or death certificate. To amend
or correct a birth or death certificate, the processing time is approximately two (2) to four (4)
weeks upon our office receiving all the required documents and information.
The Office of Vital Records processes all requests in the order received. The Office of Vital
Records does not have an expedited process to ensure fairness to all our customers.
Once our office processes your request, it will be picked in the next business day’s mail. The
amended / corrected certificate will be mailed via standard U.S. mail. You may include a pre-
paid self-addressed stamped envelope to receive the mail quicker upon our processing.
Please remember to read the guide and all instructions closely to avoid your request being
rejected and returned to you.
The correction and the fee of $40.00 will provide the applicant with one (1) certified copy of the
corrected certificate. If the applicant wants additional certified copies of the certificate, please
complete the enclosed “Certificate Application” to request additional certified copies. Please
follow all instructions on this application when requesting additional certificates.
Remember to include the following:
Affidavit for Correction of a Record form OR an original certified court order from a
U.S. District Court
Other verifiable evidence as listed in the “Amendment Chart” OR a Supplemental
Affidavit
Proper payment by check, money order, cashiers check or credit card. If paying by credit
card, an Authorization for Credit Card Use form is included in this packet.
Thank you,
Office of Vital Records
Amending / Correcting a Birth or Death Certificate
Per Nevada Administrative Code 440.023, 440.030 & 440.035
When a Court Order is Required
A court order by a court of competent jurisdiction is required for the following fields, unless a data
entry error can be proven at the time the record was created.
If an error can be proven regarding a name that would normally require a court order
Marital status on a death record
Any name on a birth or death record, except for the following:
o A middle name to a middle initial
o A middle initial to a middle name
o Informant’s name on a death record
o Child’s last name (only) on a birth record when adding a father AND changing the
child’s last name to the father’s last name
Affidavit for Correction of a Record When a Court Order is NOT Required
The rest of this guide is to aid in the process of correcting information on a birth/death certificate
when an affidavit is the appropriate method to amend the certificate. The Affidavit for Correction of
a Record form has been revised and the Supplemental Affidavit form has been created. Both forms
are available on our website at:
http://dpbh.nv.gov/Programs/BirthDeath/dta/Forms/Birth/Death_Vital_Records_-_Forms/
Please note a notation will be placed on the certificate noting an amendment / correction was
processed along with the section(s) amended, unless the court orders a new certificate to be issued.
The requirements and process to correct the information on a birth/death record are as follows:
Who May Apply for Amending the Birth Certificate
The person of record; or
The parent or guardian of the person of record; or
A legal representative of the person of record.
Who May Apply for Amending the Death or Fetal Death Certificate
The funeral director listed on the record; or
The informant listed on the record; or
The certifier listed on the record.
Who May Apply for Amending Medical Information on a Certificate
Pursuant to NAC 440.023 (2), a request to correct medical information on a certificate must
originate with the certifier of the medical information. The certifier listed on the record must sign
(witness) the Affidavit for Correction of a Record form.
Medical information:
Birth certificate: There is no medical information on the birth certificate.
Death or Fetal Death certificate: The date of death, time of death, hospital
(institution), and any section in Cause of Death / Cause.
Documentation Required to Correct a Certificate: (TWO (2) Documents to complete the
process)
Affidavit for Corrections of a Record
This form must be signed (witnessed) by an individual as outlined above on who may can apply.
The “State of Corrections” (item # 8 a and 8b) must be completed concisely and accurately.
-AND-
ONE of the following documents MUST be provided with the Affidavit for Corrections of a Record:
Other Verifiable Evidence
A document that verifies and proves each correction being requested.
A court order from any U.S. District Court is also acceptable as other verifiable evidence.
Any document submitted as other verifiable evidence that is in a language other than English
must be accompanied by a certified translated version of that document. The translation must
be completed by someone authorized to translate documents.
-OR-
Supplemental Affidavit
This form must be completed by an individual that has personal knowledge and can attest to
the correction being requested on the primary affidavit. This personal knowledge is gained
through firsthand experience or observation, through a personal, familial, medical, or a
professional relationship with the person of the record being amended.
This form must clearly and concisely explain how the person signing (witnessing) the form has
knowledge of the information being corrected.
This form must be completed in its entirety by an individual other than the person who signed
(witnessed) the Affidavit for Corrections of a Record.
When Submitting any Affidavit
The document must be notarized.
The document must be completed in its entirety.
The document cannot contain any write overs, cross outs or white outs.
The document must be accurately completed with correct information.
The individual signing (witnessing) this form must be at least 18 years of age.
The document form must be legible.
The document must be typed or completed in blue or black ink.
Fees
Correcting a Record on file with the State Registrar (including one certified copy of the amended
certificate): $40.00
Additional certified copies of a birth/death certificate: $20.00 EACH.
Correcting a Record on file with the State Registrar filed by the certifier and the State Registrar
determines that the correction is not the result of an error by the certifier: $10.00.
How to Submit Documents
In person or by mail:
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
BIRTH
DEATH
AFFIDAVIT FOR CORRECTION OF A RECORD
State Affidavit No.____________
INFORMATION
AS REPORTED
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE
1a. FIRST NAME
1b. MIDDLE NAME
1c. LAST NAME
2. SEX
4. PLACE OF OCCURRENCE (City or County)
5. NAME OF PARENT / FATHER
6. NAME OF PARENT / MOTHER (LAST NAME PRIOR TO FIRST MARRIAGE (MAIDEN - IF BIRTH RECORD)
STATEMENT
OF
CORRECTIONS
7.
ITEM
NUMBER
8a.
FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD
8b.
FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
WHY ARE
CORRECTIONS
NECESSARY?
9.
I, ___________________________________, currently residing at ___________________________________________________________,
(Print Full Legal Name) (Print Street, City, State, Zip Code)
in relation to the person of record being amended, _____________________, certify and declare under penalty of perjury under the laws of
(Print Relationship)
the State of Nevada, that all assertions of this affidavit are true and accurate to the best of my knowledge.
Witness Signature: ___________________________________________
(Sign in the Presence of a Notary)
_______________________________________________________________________________________________________________________________________________________________________________________________
State of _________________,
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of Person Making the Statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within instrument
and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s 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
Nevada that the foregoing paragraph is true and correct.
Notary Public: __________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public)
Reserved for Notary Seal
INSTRUCTIONS (PLEASE READ CAREFULLY)
Who can submit an Affidavit for Correction of a Record?
To correct a BIRTH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as the
person whose birth is registered on the certificate, his/her parent, guardian, or a legal representative. Medical information
must be by the certifier.
To correct a DEATH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as the
funeral director, certifier or informant listed on the certificate. Medical information must be by the certifier.
What do I need to submit with the Affidavit for Correction of a Record?
Other verifiable evidence (see “Amendment Chart”) proving the facts contained in the principal affidavit OR a
supplemental affidavit (see Guide) executed by a person other than the affiant of this Affidavit for Correction of a Record .
The payment of $40.00 (includes one certified copy of the corrected certificate). Additional certified copies of a birth
certificate or death certificate is $20.00 each. The payment may be made by check, cashier’s check, money order or credit
card. Please make your check, cashier’s check or money order out to the Nevada Office of Vital Records. To pay by credit
card, an Authorization for Credit Cards Use form must be completed and submitted.
PLEASE NOTE: The fee for correcting a birth or death record where the correction is filed by a certifier and the State Registrar
determines that the correction is not the result of an error by the certifier is $10.00.
How do I properly complete the Affidavit for Correction of a Record?
This is a legal document. Please type or print clearly in blue or black ink only. Illegible completion of the form will be
returned. Any white outs, cross outs or write overs will not be accepted. The Affidavit for Correction of a Record must be
fully completed in order to be processed.
Signature of the witness must be notarized. Signatures of a minor will be questioned. The person should be at least 18
years of age to make a correction.
Please complete the section titled “Statement of Corrections” clearly and accurately.
Where do I send the Affidavit for Correction of a Record and supporting documents?
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Please allow 2 – 4 weeks to process your request. Any questions regarding correcting a record should be addressed to the Office
of Vital Records at the above address, or by calling our office at 775-684-4242. Please provide the name, full address of where
the certificate should be mailed to and phone number:
..........................................................................................................................................................................................................................................
Name
..........................................................................................................................................................................................................................................
Street Address or P.O. Box
..........................................................................................................................................................................................................................................
City
State
Zip Code
..........................................................................................................................................................................................................................................
Phone Number
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
BIRTH
Check One Leave Blank
DEATH
AFFIDAVIT FOR CORRECTIONS OF A RECORD
State Affidavit No.____________
INFORMATION
AS REPORTED
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE
1a. FIRST NAME
List the Person of Record (POR)
1b. MIDDLE NAME
Same as 1 a
1c. LAST NAME
Same as 1a
2. SEX
POR
4. PLACE OF OCCURRENCE (City or County)
List the city and/or county where the birth or death occurred at
5. NAME OF PARENT / FATHER
List a parent of the person of record (Must match record)
6. NAME OF PARENT / MOTHER (LAST NAME PRIOR TO FIRST MARRIAGE (MAIDEN - IF BIRTH RECORD)
List a parent of the person of record (Must match record)
STATEMENT
OF
CORRECTIONS
7.
ITEM
NUMBER
8a.
FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD
8b.
FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
See
List individually the errors on the record
List individually the correct information
Items
List
WHY ARE
CORRECTIONS
NECESSARY?
9. Clearly and concisely explain why the corrections are necessary
I, ________Witness print name here _____, currently residing at _Address where you reside or are located at (Not a P.O. Box)___
(Print Full Legal Name) (Print Street, City, State, Zip Code)
in relation to the person of record being amended, Listed in the instructions, certify and declare under penalty of perjury under the laws of
(Print Relationship)
the State of Nevada, that all assertions of this affidavit are true and accurate to the best of my knowledge.
Witness Signature: _Signature of the person listed here____________
(Sign in the Presence of a Notary)
_______________________________________________________________________________________________________________________________________________________________________________________________
State of _________________, THIS SECTION IS COMPLETED BY THE NOTARY
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of Person Making the Statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within instrument
and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s 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
Nevada that the foregoing paragraph is true and correct.
Notary Public: __________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public)
Reserved for Notary Seal
SUPPLEMENTAL AFFIDAVIT (Per NAC 440.030)
PRINT FULL LEGAL NAME: ________________________________________________________________________________
Physical Address: ___________________________________________________________________________________________
City: ________________________________________ State: _________ Zip Code: ______________
E-mail Address: ______________________________________________________ Phone Number: _____________________
I, _____________________________________, certify and declare under penalty of perjury under the laws of the State of Nevada,
(Print Name)
that I have personal knowledge to attest to the information provided in the primary affidavit for ____________________________,
(Person of Record)
and I swear that all the assertions of this affidavit, including my identity, are true and accurate.
My relationship to the person of record is _________________________, and I have this personal knowledge through the
(Relationship)
following course of events: ___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Signature: ___________________________________________
(Sign in the Presence of a Notary)
State of _________________,
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of person making the statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within
instrument and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s 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 Nevada that the foregoing paragraph is true and correct.
Notary Public: _________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public) Reserved for Notary Seal
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
SUPPLEMENTAL AFFIDAVIT (Per NAC 440.030)
PRINT FULL LEGAL NAME: _Full legal name of the person attesting to the information _____________________________
Physical Address: _Physical address or location of the person listed above (Not a P.O. Box)___________________________
City: __For the person listed above_________________ State: _________ Zip Code: ____________
E-mail Address: __For the person listed above_____________________________ Phone Number: _____________________
I, ___Same person as listed above______________, certify and declare under penalty of perjury under the laws of the State of Nevada,
(Print Name)
that I have personal knowledge to attest to the information provided in the primary affidavit for Person whose record is being corrected,
(Person of Record)
and I swear that all the assertions of this affidavit, including my identity, are true and accurate.
My relationship to the person of record is _For the person listed above___________, and I have this personal knowledge through the
(Relationship)
following course of events: _Explain in detail HOW you (the person listed above) has personal knowledge of the_______
information being corrected. The personal knowledge must be through firsthand experience. This person cannot be the
same person signing the “Affidavit for Correction of a Record” form. ___________________________________________
Signature: __Signature of the person listed above_________
(Sign in the Presence of a Notary)
State of _________________, THIS SECTION IS COMPLETED BY THE NOTARY
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of person making the statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within
instrument and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s 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 Nevada that the foregoing paragraph is true and correct.
Notary Public: _________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public) Reserved for Notary Seal
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
BIRTH CERTIFICATE AMENDMENT CHART
(NRS 440.155, NAC 440.023, NAC 440.026, NAC 440.030, NAC 440.035)
Other Verifiable Evidence Accepted is a document from an independent source containing information that supports/proves the request to correct the
birth certificate.
Supplemental Affidavit must be submitted by an individual, other than the person who executed the Affidavit for Correction of a Record, with personal
knowledge of the item being amended. This personal knowledge is gained through firsthand experience or observation, through a personal, familial,
medical, or a professional relationship with the person of the record being amended.
Other documentation, not listed below, may be considered as Other Verifiable Evidence; however, ALL documents are subject to approval by the
Office of Vital Records.
Documentation showing cross-outs, white-outs, or alterations of any kind will not be accepted as Other Verifiable Evidence.
1
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Child’s Name
(First, Middle, Last,
Suffix)
Court Order
Certified Court Order
No
Listed on the Birth
Certificate
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Birth Worksheet submitted by the hospital or a verifiable copy
Child’s First and/or
Middle Name
omitted
Affidavit for
Correction of a
Record
Original Declaration of Paternity or Parentage
Yes
Child’s Middle
Name changed to
Middle Initial only
Affidavit for
Correction of a
Record
Child’s Birth Certificate
Verification of Birth Certificate
No
Child’s Middle
Initial changed to
a Middle Name
Court Order
Certified Court Order
No
2
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Child’s Date of Birth
Affidavit for
Correction of a
Record
Hospital Record of Birth
Physician Record of Birth
Yes
Time of Birth
Affidavit for
Correction of a
Record
Hospital Record of Birth
Physician Record of Birth
Yes
Sex
Affidavit for
Correction of a
Record
For Correction:
o Hospital Record of Birth
o Physician Record of Birth
Yes
For Gender/Sex Change:
Letter from Healthcare professional stating that individual
currently, and will continue to identify as the sex stated in
affidavit.
Yes
Facility Name
Affidavit for
Correction of a
Record
Hospital Record of Birth
Physician Record of Birth
Insurance Explanation of Benefits/Billing
Yes
City, Village or Location
of Birth
Affidavit for
Correction of a
Record
Hospital Record of Birth
Physician Record of Birth
Insurance Explanation of Benefits/Billing
Yes
County of Birth
Affidavit for
Correction of a
Record
Hospital Record of Birth
Physician Record of Birth
Insurance Explanation of Benefits/Billing
Yes
3
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Parent/Mother’s Current
Legal Name
(First, Middle, Last)
Spelling Error,
Omitted Name, or
Transposing of
First, Middle, Last
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Birth Worksheet submitted by the hospital or a verifiable copy
Parent/Mother’s Birth Certificate
Certificate of Naturalization
No
Incorrect Name
Court Order
Certified Court Order
No
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Birth Worksheet submitted by the hospital or a verifiable copy
Parent/Mother’s Date of
Birth and/or
Mother’s Age
Affidavit for
Correction of a
Record
Parent/Mother’s Birth Certificate
Physician Record of Parent/Mother’s Birth
Hospital Record of Parent/Mother’s Birth
Birth Worksheet submitted by the hospital or a verifiable copy
Certificate of Naturalization
Yes
4
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Parent/Mother’s Name
Prior to First Marriage
(Last, Suffix)
Court Order
Certified Court Order
No
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Parent/Mother’s Birth Certificate
Birth Worksheet submitted by the hospital or a verifiable copy
No
Parent/Mother’s Birth
Place
Affidavit for
Correction of a
Record
Parent/Mother’s Birth Certificate
Physician Record of Parent/Mother’s Birth
Hospital Record of Parent/Mother’s Birth
Birth Worksheet submitted by the hospital or a verifiable copy
Yes
Parent/Mother’s
Residence
State
County
City, Town or
Location
Street
Apt No.
Zip Code
Inside City Limits
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at time of
child’s birth, listing one or both parents
Birth Worksheet submitted by the hospital or a verifiable copy
Yes
5
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Parent/Father’s Current
Legal Name (First,
Middle, Last, Suffix)
Spelling Error, or
Transposing of
First, Middle, Last,
Suffix
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Birth Worksheet submitted by the hospital or a verifiable copy
Parent/Father’s Birth Certificate
Certificate of Naturalization
No
Court Order
Certified Court Order
No
Incorrect Name
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Birth Worksheet submitted by the hospital or a verifiable copy
Parent/Father’s Date of
Birth and/or
Parent/Father’s Age
Affidavit for
Correction of a
Record
Parent/Father’s Birth Certificate
Physician Record of Parent/Father’s Birth
Hospital Record of Parent/Father’s Birth
Birth Worksheet submitted by the hospital or a verifiable copy
Certificate of Naturalization
Yes
Parent/Father’s
Birthplace
State
Territory or
Foreign Country
Affidavit for
Correction of a
Record
Parent/Father’s Birth Certificate
Physician Record of Parent/Father’s Birth
Hospital Record of Parent/Father’s Birth
Birth Worksheet submitted by the hospital or a verifiable copy
Yes
6
Field on Birth
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Certifier’s Name
Title
Affidavit for
Correction of a
Record
Hospital Record of Birth
Yes
(by Hospital ONLY)
Attendant’s Name
Title
Attendant’s
Address
Affidavit for
Correction of a
Record
Hospital Record of Birth
Yes
(by Hospital ONLY)
Date Certified
Affidavit for
Correction of a
Record
Hospital Record of Birth
Yes
(by Hospital ONLY)
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
(Rev 07/16/2018) (775)684-4242
Birth Certificate Item Numbers
For Affidavit for Correction of a Record Form
1.
Child’s name
2.
Date of birth
3.
Time of birth
4
Sex
5
Facility name
6
City, Village, or location of birth
7
County of birth
8a
Mother/Parent current legal name
8b
Mother date of birth
8c
Mother age
9.
Mother’s name prior to first marriage
10.
Mother’s birthplace
11a..
Residence of Mother (state)
11b.
Mother’s County
11c.
Mother’s city, town, or location
11d.
Mother’s street and number
11e.
Mother’s apt. no
11f.
Mother’s zip code
11g.
Inside city limits
12a.
Father/Parent current legal name
12b.
Father’s date of birth
12c.
Father’s age
12d.
Father’s birthplace
13a.
Certifier’s name
14a.
Attendant’s name
15a.
Certifier or Attendant’s signature
15b.
Date Certified
16a.
Registrar’s signature
16b.
Date filed by registrar
State of Nevada
Division of Public and Behavioral Health
Bureau of Preparedness, Assurance, Inspections and Statistics
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242
http://dpbh.nv.gov
APPLICATION FOR A CERTIFIED BIRTH CERTIFICATE COPY OR VERIFICATION
A COPY OF THE APPLICANT’S PHOTO IDENTIFICATION AND FULL PAYMENT IS REQUIRED FOR ALL
REQUESTS. PROOF OF RELATIONSHIP IS REQUIRED FOR CERTIFICATE REQUESTS. Make payment payable to:
Office of Vital Records. Checks, money orders and credit cards are accepted. Please include an Authorization for Credit Card Use
form if paying by credit card.
Name of the Person on the Certificate:
First
Middle
Last
Date of Birth
County of Birth
State of Birth
Parent’s First and Last Name
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a legal
relationship or a need to facilitate a legal process to receive a certified copy of a certificate. Below, indicate your relationship
or your legal need for this certificate. Please provide proof such as a birth certificate or court order, unless the applicant is the
person of record or a parent listed on the certificate. The request will be rejected if sufficient proof is not provided. Visit
our website listed above for more information regarding proof required.
Relationship and Reason for Request
Applicant’s Printed Name
Applicant’s Signature
Applicant’s Address
Applicant’s Phone Number
FOR OFFICE USE ONLY
Receipt number: _________________________ Date: ______________________
Rev. (02/15/2017)
Number of Copies
FEE FOR A CERTIFIED BIRTH CERTIFICATE COPY
$20.00 per certificate
X
TYPE OF CERTIFICATE (Please check one type box below)
Certificate(s) to read as “Mother / Father”
Certificate(s) to read as “Parent / Parent”
X
VERIFICATION ONLY
Verifies the existence of a record with the State of Nevada and does not include a certified copy.
Search/Verification - $10.00 per search / verification
X
LETTER OF PATERNITY ONLY
Only available to the parent(s) listed on the birth certificate or a federal, state or county agency.
Letter of Paternity - $10.00 per search / letter
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DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology)

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Completed 12 May 2021

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