P.O.
(336)318-6960
***BIRTH CERTIFICATE
Full Name at Birth_____________________________________________________________________
Date of Birth__________________________________________________________________________
Father’s Full Name_____________________________________________________________________
Mother’s Full Maiden Name______________________________________________________________
***DEATH CERTIFICATE
Full Name of Deceased___________________________________________________________________
Date of Death___________________________________________________________________________
Number of copies________________________________________________________________________
***MARRIAGE CERTIFICATE
Full Name of Groom_____________________________________________________________________
Full Maiden Name of Bride________________________________________________________________
Date of Marriage_________________________________________________________________________
THE CERTIFICATE OF THE ABOVE NAMED PERSON IS:
1. My Self
2. My Spouse
3. My Brother
4. My Sister
5. My Child/Step Child
6. My Parent/Step Parent
7. My Grandchild/Grandparent
8. I am seeking information for legal determination of personal or property rights.
9. I am an authorized agent, attorney, or legal representative of the person listed above. (Proof required)
10. Other ____________________________
I hereby certify that all the above information given is true to the best of my knowledge and belief.
__________________________________ ___________________________________
Applicant’s Signature Date of Request
__________________________________ ___________________________________
Address ID Information
__________________________________
City/State