# of copies:
State Abstract (Texas-wide 1926-present)
Long Form (San Antonio births only)
$23
Certified Copy (1 copy, Bexar county only)
$21
$23
Additional Certified Copies
$4
Total (Check or money order payable to City of San Antonio)
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I) - If requesting a death record, date of DEATH is required.
Full Name of
Person
on Record
First Name Middle Name
Last Name
Date of Birth/Death
Month Day Year Sex
Place of
Birth/Death
City or Town County
State
Full Name of
Parent 1
First Name Middle Name Maiden Name/Last Name
Full Name of
Parent 2
First Name Middle Name
Maiden Name/Last Name
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address: Street Address City State Zip
Relationship to person listed above
Purpose for obtaining this record:
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF COUNTY OF Before me on this day appeared _______________________________________
(Applicant name)
now residing at ____________________________________________________________________________________________________________
(Address) (City) (State)
who is related to the person named on Part I as ___________________________________and who on oath deposes and says that the contents of this
affidavit are true and correct. (Relationship)
The applicant presented the following type and number of identification:
Applicant Signature______________________________________________
Sworn to and subscribed before me, this day of , 20 .
(Seal) Signature of Notary Public and Notary ID Number___________________________________________
Typed or Printed Name: _______________________________________________________________
Commission Expires: ________________________________________________________________
Street Address:_____________________________________________________________________
City, State, Zip:_____________________________________________________________________
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.
)
MAIL THIS APPLICATION, PAYMENT, AND A VALID PHOTO ID TO:
DEPARTMENT OF VITAL RECORDS
719 S SANTA ROSA
SAN ANTONIO, TX 78204
For questions or assistance, we can be reached at (210) 207-8781.
OFFICE USE ONLY
File No:
Sheet No:
City of San Antonio
Office of the City Clerk
Vital Records Division
MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST. A check or
money order is required and payable to: City of San Antonio. All funds are deposited directly to the City of San Antonio Accounts.
If paying by check, checkholder/signee ID must be included. Please note, selecting a postage fee is REQUIRED for all mail orders and
priority mail service will require a signature upon delivery. Proof of relationship is required for non-self or non-parental applicants.
Priority Postage (3-5 business days)
$13
Overnight Service
$24.25
# of copies:
Total (Check or money order payable to City of San Antonio)
Overnight Service
$24.25
$13
Priority Postage (3-5 business days)
$
$
$
$
$
$
$
$
Plastic Sheet Cover
$2
Plastic Sheet Cover
$2
$
$
$
$
