Fill and Sign the Vital Records Authorization Form

Vital Records Authorization Form _______________________ ________________________________ ________________________________ (Name and Address of County or State Official) Instructions Order Number: ___________1.Verify that all information below is correct.2. Print and complete this form.3. Sign and date the form. (If notarization section is included below, signature must occur in the presence of a Notary Public.)4. Fax the completed form and the copy of your ID to _____________________ (fax number).5. Please fax only the Authorization Form and ID copy. Do not include a cover sheet. Sworn Statement STATE OF ____________________COUNTY OF _______________________PERSONALLY appeared before me, the undersigned authority in and for said county and state, _______________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: I am an authorized person, as defined in the _______________________ (Name of State) Health and Safety Code, Section ___________, and am eligible to receive a certified copy of the birth, death or marriage record of the following individual(s): _______________________ (Name of Person Listed on Certificate)_______________________ (Relationship to Person Listed on Certificate)___________________________________ (Printed Name of Affiant)___________________________________(Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____._____________________________NOTARY PUBLICMy Commission Expires:___________________