The Great Seal of the County of Santa Cruz  County of Santa Cruz, Health Services Agency, Vital Statistics
 1080 Emeline Avenue, Santa Cruz, CA 95060  | Phone: 831 454 4020
 Hearing Impaired TDD: 831 454 2123 | copyright©  2000 County of Santa Cruz

Birth or Death Certificate Request Form
This is an application to request a "certified" copy of a birth or death certificate. Please print this page, fill in the following information, enclose a check or money order and send to the address on the top of this form.

*NOTE: HSA Vital Statistics only processes requests for births/deaths within the last 2 years. Contact the County Recorders office (701 Ocean St., Santa Cruz, CA., (831) 454-2800) for certificates for births/deaths over 2 years ago.

Place an X near the certificate you want to order:

 

_____ Birth Certificate ($18.00 per copy ---- Number of copies: __________)

 

_____ Death Certificate ($13.00 per copy ---- Number of copies: __________)

 

Amount Enclosed: $ _______________________



Name of Individual on Certificate:
___________________________________________________

                                                                  First                            Middle                               Last

 

Date of Birth or Death: ___________________ City: _______________________State: _______

 

 

Name of Person Requesting Certificate: _________________________________________________
                                                                     First                             Middle                               Last

                                       

For Birth Certificates only:

 

Fathers Full Name: ___________________________________________________________
                                                       First                             Middle                               Last

 

Mothers Full Maiden Name: ____________________________________________________
                                                       First                             Middle                               Last

Hospital or Location: ________________________________   Sex: Male ___  Female ___

Relationship: (check one)  Self ___  Mother ___  Father ___  Other _____________________


Mail to Information:


Mail To Name: __________________________________________________

Address: _______________________________________________________

City: __________________________ State: __________ Zip: __________

Phone Number: _________________________________