Indiana Birth Certificate Request

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					          Order your Birth Certificate with online or faxed applications @ www.vitalcheck.com
                LAPORTE COUNTY HEALTH DEPARTMENT
       YOU MUST HAVE A              VITAL RECORDS DIVISION                             PICTURE IDENTIFICATION
                                  BIRTH CERTIFICATE REQUEST
                    WARNING: False application, altering, mutilating, or counterfeiting
                    Indiana birth certificates are a criminal offense under IC 15-1-19-6.

Birth Certification - $7.00 per certified                            FOR OFFICE USE ONLY
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LaPorte Main Office (219) 326-6808 ext 200 Book # ____________ Page # __________
809 State Street – Suite 401A
LaPorte, IN 46350-3385                              Local # ____________ File Date __________
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Michigan City Branch Office (219) 874-3755                  Number of Copies: __________
302 West 8th Street – Suite #3
Michigan City, IN 46360 FAX ID to (219) 873-3018 for ALL credit card requests
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           YOU MUST HAVE BEEN BORN IN LAPORTE COUNTY AND
          YOU MUST BE 18 years old TO GET A BIRTH CERTIFICATE!!!
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Were the Parents of the Person in item #1 MARRIED at time of Birth?                 Yes _______ No _______
1. FULL NAME @ BIRTH_________________________________________________
       or LEGAL NAME IF CHANGED by (Adoption, Paternity or Legitimations):
                       _______________________________________________________

2. DATE of BIRTH ________________ BORN: At Home ______   Hospital ______
3. PLACE of BIRTH – CHECK ONE:
     LAPORTE         _____     MICHIGAN CITY _____   LAPORTE Co. _____

4. FULL NAME of FATHER: _____________________________________________
     STATE of BIRTH for the FATHER: ___________________________________

5. FULL MAIDEN NAME of MOTHER: _____________________________________
     STATE of BIRTH for the MOTHER: ___________________________________
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6.                                                        7.
     Please PRINT your current name                             SIGNATURE – of your current name


Your Relationship to the person in item #1                                   Street Address


     What you need this certificate for                     City                   State                   Zip


   INCLUDE A COPY OF DRIVERS                      Telephone #
   LICENSE or OTHER PICTURE ID
NO PERSONAL CHECKS OR CREDIT ACCEPTED FOR MAIL OR IN PERSON REQUESTS

				
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