Fillable Parke County Health Department (Parke County Units of Government)

Fill Online, Printable, Fillable, Blank Parke County Health Department (Parke County Units of Government) Form

Use Fill to complete blank online PARKE COUNTY UNITS OF GOVERNMENT (IN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Parke County Health Department (Parke County Units of Government)

On average this form takes 8 minutes to complete

The Parke County Health Department (Parke County Units of Government) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Parke County Units of Government

BROWSE PARKE COUNTY UNITS OF GOVERNMENT (IN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Parke County Health Department
116 W High Street Room 12 Phone: 765-569-6665
Rockville, IN 47872 FAX: 765-569-4061
parkehealth@parkecounty-in.gov parkecounty-in.gov
GENEALOGY ONLY
Application for birth or death record for genealogy only Date Received_______________
BY INDIANA STATE LAW; IC 16-37-1-8
ALL RECORDS THAT ARE NOT 75 YEARS OLD ARE CONFIDENTIAL RECORDS and cannot be issued except to the individual named on the record or an
immediate member of the family, who produces required identification. Required identification is a photo ID and birth certificate(s) indicating
relationship to individual named on record.
Please include a self-addressed stamped envelope.
PLEASE PRINT
Full name______________________________________Date of birth____________________Date of death________________
Parents______________________________________________ ___________________ _________________________
(father) (mother)
Full name_____________________________________Date of birth____________________Date of death_________________
Parents______________________________________________ _______________________________________________
(father) (mother)
Full name_____________________________________Date of birth____________________Date of death_________________
Parents______________________________________________ ________________________________________________
(father) (mother)
APPLICANT__________________________________________________________PHONE_______________________________
Address_________________________________________________________________________________________________
Street City State Zip
Genealogy Research is $10.00 per hour (1 hr minimum) Office Use:
When found certified birth $10.00 ea Date Received:___________________________________
When found certified death $10.00 ea Certificates Issued:________________________________
Issued by:_______________________________________
Research fee:____________________________________
Payment type and amount:_________________________
Acceptable payment types are cash, check, money order, Discover, Visa, or Mastercard. When paying by
credit or debit cards, you must either pay in person or print a “Credit/Debit Authorization form and mail
BEFORE research will be done. There is either a 3% convenience fee or a $1 minimum (if transaction is
under $33.00) for all debit and credit card transactions.
2
Credit/Debit Card Payment Authorization Form
Please complete and sign this form to authorize the Parke County Health Department to make a debit to your
credit/debit card listed below. By signing this form you give us permission to debit your account for any fees due.
Please complete the information below:
I, ___________________________________________ authorize the Parke County Health Department to charge my
credit card account for the amount due for licenses, permits, or vital record searches and productions on or after
___________________.
Signature ________________________________________
Signature Date_____________________________________
I authorize the above named business to charge the credit card indicated in this authorization form according to the
terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute the payment
with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Name _________________________________________________
Billing Address _________________________________ Phone#___________________________________
City, State, Zip _________________________________ Email ____________________________________
**Disclaimer: The Parke County Health Dept will not retain credit/debit card information, upon authorization of
applicable fees, everything below the dotted line will be destroyed.
Office Use Only:
Authorization Number _______________________ Initials_____________ Date of transaction___________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Account Type: Visa MasterCard Discover
Account Number _____________________________________________ Expiration Date ________________________
3 Digit Security Code ___________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Parke County Health Department (Parke County Units of Government)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document