Form Revised: 12/31/2013
EL DORADO COUNTY VITAL STATISTICS
APPLIC
ATION FOR COPY OF BIRTH OR DEATH CERTIFICATE
Please indicate the items you would like to receive:
Birth Certificate
$28 each
Quantity
Death Certificate
$21 each
Quantity
Please Print or Type
Information About Person Requesting Certificate:
Your Name and Address Telephone Number (Include Area Code)
Driver’s License No.
Information About Person Listed On Certificate:
Name As Appearing On Certificate Sex
First Middle Last
Date of Birth or Death (Month, Day, Year) Father’s Name Mother’s Maiden Name
For Birth Certificates Only
OFFICE USE ONLY
Hospital Name (if applicable) City/Town of Birth
Date Application Received
Date Application Processed
For Death Certificates Only
Total Amount Paid
Social Security Number City/Town of Death
Method of Payment
Certificate Number
The California Health and Safety Code, Section 103526, permits only authorized persons (as defined below) to receive certified
copies of birth and death certificates. Persons not authorized to receive a certified copy will receive an informational copy marked
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY." Please mark requested type below.
Informational Copy – Do NOT select from items (1) through (6) below or sign the Sworn Statement.
Certified Copy – DO select from items (1) through (6) below, as applicable. Complete the following Sworn Statement (for
in-person requests) or attach a separate Notarized Sworn Statement (for mail-in requests, as required).
I am:
(1) The registrant or a parent or legal guardian of the registrant.
(2) 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.
(3) A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who
is conducting official business.
(4) A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
(5) 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.
(6) An agent or employee of a funeral establishment acting within the course and scope of employment and ordering
certified copies of a death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive of
subdivision (a) of Section 7100 of the Health and Safety Code.
SWORN STATEMENT: Complete th e follo wing in the presence of Vital Statistics staff fo r cert ified cop y requ ests m ade in -
person at the Vital Statistics Office. (Attach a separate Notarized Sworn Statement for mail-in requests, as required.)
(Print Name)
I, _______________________________________ , swear under penalty of perjury under the laws of the State of California, that I
am an authorized person, as defined in California Health and Safety Code 103526 (c), and am eligible to receive a certified copy of
the birth or death certificate requested above.
Sworn this: day of , at Placerville, California
(Day)
(Month) (Year)
Signature:
