Fillable Form 96932: that name INFORMATION FOR THE It

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Form 96932: that name INFORMATION FOR THE It

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OFFICE OF VITAL
STATISTICS
Department
of
Public
Health
and
Social
Services
P.O.
Box2816
Hag~tfia,
Guam
96932
APPLICATION
FOR
A
COPY
OF
BIRTH
U
DEATH
~
MARRIAGE
Li
CERTIFICATE
PRINT
ALL
ITEMS
CLEARLY
FIRST
NAME
MIDDLE
LAST
NAME
AT TIME
OF
BIRTH
2.
DATE
OF
BIRTH;
MONTH
DAY
YEAR
3.PLACE
OFBIRTH:
4.
FATHER’S
NAME:
FIRST
5.
MOTHER’S
MAIDEN
NAME:
6.
DATE
OF
MARRIAGE:
MONTH
8.
BRIDE’S
NAME:
9.
GROOM’S
NAME:
10.
DATE OF
DEATH:
DAY
YEAR
FIRST
MIDDLE
FIRST
MIDDLE
MONTH
DAY
YEAR
7.
PLACE
OF
MARRIAGE:
LAST
LAST
11.
PLACE
OF
DEATH:
NUMBER
OF
COPIES
DESIRED:
________
CERTIFICATE
NUMBER,
IF KNOWN:
RELATIONSHIP TO
PERSON
NAMED
IN
ITEM
ONE
(1).
IF
SELF,
STATE
“SELF”:
_______________________
NOTE:
A copy
of
a
birth,
death,
or
marriage
certificate can
be
issued
ONLY
to
a
person
to whom the
record
relates,
if
of
age,
or
a
parent
or
other
legal
representative.
IF
THIS
REQUEST
iS
NOT
FOR
YOUR
OWN
RECORD OR
THAT
OF
YOUR
CHILD,
PROPER
WRITTEN
AUTHORIZATION
FROM
THE
PERSON
MUST BE
PRESENTED
WITH
THIS
APPLICATION.
PRINT AND
SIGN
YOUR
NAME
AND ADDRESS
BELOW
FEE:
Pursuant
to
10
GCA
Chapter
3,
Section
3127,
a
fee
of
$5.00
is
charged
for
each
Certified
COPY
issued.
Fees
must
be
paid
at
the
time
the
application
is
made.
Applicants
are
advised
not to send
cash.
Certified
checks
or
postal
money
orders
should
be
made
payable
to
the TREASURER
OF
GUAM.
Stamps,
foreign
currency,
personal
checks, and
Credit
cards
will
not
be
accepted.
~p
FAX
SERVICES
AVAILABLE.
NO
CERTIFICATES
WILL BE
SENT
BY
FAX.
INFORMATION
FOR THE
APPLICANT:
It
is
absolutely
essential
that
the
name
be
accurately spelled and
that
the
exact
date
—
month,
day,
and
year
—
the
exact place
of
birth
(name
of
hospital)
be ftilly
given
in
every
application.
For
Marriage Certificates, indicate
the
Bride’s
complete
name
at the
time
the
Marriage
License
was
issued.
1.
NAME:
MIDDLE
FIRST
i~vu
ur
nv~ri
,u.
OR
VILLAGE
LAST
MIDDLE LAST
Name:
________________________________________
Signature:
_______________________________________
Address:
City:
________________________________
State:
_____________
Zip
Code:
___________
PRINT
Download
Clear Form
DEPARTMENT
OF
PUBLIC
HEALTH
AND
SOCiAL
SERVICES
OFFICE
OF
VITAL
STATiSTICS
FEES
FOR
VITAL
STATISTICS
RECORDS
AND
AMENDMENTS
TheDepartment
of
Public
Health
and
Social
Services,Office
of
Vital
Statistics
under
authority
of
Public
Law
1590,
subsection
1
of
Section
9324
of
the
Government
Code,
annotated,
has
adopted
a
revision
of
fees
for vital
statistics
records
and
amendments.
The
following
is
a
listing
of
the
proposed
fees:
CERTIFIED
COPIES
:
(a)
Birth
$5.00
(b)
Death
5.00
(c)
Marriage
5.00
(d)
Birth
Registration
Card
5.00
Cedula
Number
5.00
Burial
Permit
5.00
Disinterment
Permit
5.00
Processing
A
mendments
(a)
Change
of
Name
(courtorder)
10.00*
(b)
Legitimation
10.00*
(c)
Affidavit
of
Paternity
10.00*
(d)
Declaration
of
Paternity
10.00*
(e)
Any
other
amendments
10.00*
Adootion
15.00*
Filing
Delayed
Certificate
(a)
Birth
10.00*
(b)
Marri~e
10.00*
(c)
Presumptive
death
certificate
10.00*
(a)
First
3
years
5.00
(b)
Every
year
thereafter
2.00
(per
year)
*
These
fees
.22.UD.t
include
the
issuance
of
a
certified
copy.
GOVERNMENT
AGENCIES
Requests
for
official
businessfrom
Federal,
State
or ocal
governmental
agencies
shall
require
the
payment
of
appropriate
fee.
However,
governmental
agencies
requesting
large
volumes
of
servicemay
be
handled
by
contract
of
some
type
of
billing
procedure.
O\’ERPA
YMENT
Overpayment
of
the
required
fee
received
by
the
Territorial
Registrarshall
be
retained,
except
any
overpayment
shall
be
refunded
upon
written
request
of
the applicant
within
one
year
or
when
such
overpayment
is in
excess
of
two
dollars
($2.00).
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Completed 28 January 2022

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