Fill and Sign the Vital Records Authorization Form 497332398

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 PUBLIC My Commission Expires: ___________________