Application for certified copy of BIRTH or DEATH Certificate
BIRTH
# OF CERTIFIED COPIES X $23.00 (each) = $_____
DEATH
FIRST CERTIFIED COPY: $ 21.00
# OF ADDITIONAL COPIES OF SAME RECORD X $ 4.00 = $
TOTAL ENCLOSED $
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1. Full Name First Middle Last
(Person on Record)
2. Date of Month Day Year 3. Sex
Birth/Death
4. Place of City or Town County State
Birth/Death
5. Full Name First Middle
Last (Maiden)
of Parent 1
6.
Full Name
First Middle Last (Maiden)
of Parent 2
7.
Applicant’s Name :
8.
Phone Daytime:
9.
Mailing Address:
City State
Zip Code
10.
Relationship to Person in Item 1:
11.
Purpose for obtaining this record:
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING
A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE
STATEMENT IS 2 TO 10 YEARS
IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
DATE
Vital Statistics
Phone: 940-349-2018
ACCEPTABLE FORMS OF PAYMENT
INCLUDE: CASH, CASHIERS CHECK,
MONEY ORDER, BUSINESS CHECKS,
PERSONAL CHECKS AND CREDIT/DEBIT.
INSTRUCTION FOR SUBMITTING
APPLICATION BY MAIL:
"NOTARIZED PROOF OF ID", a photo copy
of valid ID, and appropriate payment form
must be included. All forms can be found at
www.dentoncounty.com/ccl or as part of this
application.
Recording Department
940-349-2010
PHOTOCOPY OF ID
MUST BE SENT IF
SUBMITTING
APPLICATION BY
MAIL OR SUBMITTING
IN PERSON.
Juli Luke
County Clerk
Denton County Courts Building
14
50 E. McKinney Street, Ste. 1103
Denton, Texas 76209
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home
Visitation Program administered by the Office of Early Childhood Coordination of the Health and Human Services.
SIGNATURE OF APPLICANT
APPLICATIONS WITHOUT SIGNATURE OF APPLICANT WILL NOT BE PROCESSED
1450 E. McKinney Street - Ste. 1103 - Denton, Texas 76209
