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County of Sante Clara FINANCE AGENCY Office of the County Clerk-Recorder County Government Center 70 West Hedding Street, E. Wing, 1" Floor San Jose, California 95110 (408) 299-5688 APPLICATION FOR CERTIFIED COPY OF A BIRTH/DEATH RECORD Notice: Orders received by mail must have the notary statement Part $ completed (see instructions). Processing time for mail requests: 15 - 20 working days The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive authorized copies of birth/death records. Those who are not authorized by law to receive the authorized copy will receive a cettified copy marked “Informational, not a valid document to establish identity” Please indicate whether you would like an authosized or an informational copy. Part 1. (2 I would like an authorized certified copy of the record 1 I would like a certified informational copy of the identified on the application form. record identified on the application form. (In order to receive the authorized copy, you must indicate your (You are not required to select from the list below in relationship to the person named on the application form by order to receive an informational copy. selecting from the list below. Complete parts 2, 3, 4, and 5) Proceed to Part 3) Pare 2. Lam: 1) The person named on the certificate, or the parent or legal guardian of the person named on the certificate. 1 Aparty entitled to receive the record as a result of a court order, of an attorney, of licensed adoption agency secking the birth record in order to comply with the requirements of Section 3140 or 7603 of the Family Code, (1 Amember of a law enforcement agency ot a representative of another governmental agency, as provided by law, who is conducting official business. A child, grandparent, grandchild, sibling, spouse, or domestic partner of the person named on the certificate. An attorney representing the person named on the certificate or the his/her estate, or any petson or agency empowered by statute or appointed by a court to act on behalf of the person named on the certificate or his/her estate. o o0 A funeral director ordering certified copies of a death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive of subdivision (a) of Section 7100 of the Health and Safety Code. Part 3. STOP! Do not complete the rest of this form before reading the attached instructions. APPLICANT INFORMATION (Please print of type) Printed name of person completing application Date Telephone Number ¢ Address - Number, Street City State | Zip Code Name of person receiving copies, if different from above: First Name Middle Name Last Name Mailing address for copies, if different from above: Street Address City State Zip Code Rev. 1- 12/2/2014 
