Health Services Agency - Birth Death Certificate Request Form

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: _________________________________