SIDNEY-SHELBY COUNTY HEALTH DEPARTMENT

REQUEST FOR BIRTH/DEATH CERTIFICATE

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BIRTH CERTIFICATE

Name at Birth ______________________________________________________________________

Date of Birth ______________________________________________________________________

DEATH CERTIFICATE

Name of Deceased _______________________________________________________________________

Date of Death _______________________________________________________________________

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COPIES REQUESTED: Certified ____________($21.50 each)

(uncertified copies are prohibited by state law)

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PERSON REQUESTING CERTIFICATE

Name _______________________________________ Date____________________________________

Address _______________________________________________________________________________________

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Phone Number___________________________________________