VITAL RECORD CERTIFIED COPY REQUEST

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					                 VITAL RECORD CERTIFIED COPY REQUEST
             Circle one:                Birth                         Death                        Marriage

Name on Certificate_______________________________________________________________________
            (Legal name at birth or death, or in the case of marriage request, groom’s full name and bride’s full maiden name.)

Date of Event_________________ Place of Event______________________________________

Father’s name and birth date _______________________________________________________
                                           (Required to order a birth certificate)


Mother’s full maiden name and birth date ___________________________________________________
                                                               (Required to order a birth certificate)


Your relationship to person named on certificate ____________________________________________
                                                 ____________________________________________

                                    Number of certified copies__________

                                                            certificate.
Birth documents maximum request is three copies of the same certificate. If more are needed, contact
                        this office. Marriage and death records, no limit.

Fees: Birth and Marriage records: $11.00 for 1st copy, additional copies $4.00 each of same certificate.
                                                 copy,                                      certificate.

         Death records: $13.00 for 1st copy, additional copies $6.00 each of same certificate.

For all document orders, one readable photocopy of your Driver’s License or State I.D. is required with
     order.
your order.



                                             Applicant Information

Name _____________________________________________________________________________

Address___________________________________________________________________________

City, State and Zip Code ____________________________________________________________

Daytime phone number ____________________________________________________________

I affirm, under the penalty of perjury, that the representations made on this application
are true to the best of my knowledge and belief.

Signature _____________________________________________ Date_______________________
                 Please make check payable to: Kane County Clerk
    Send form, ID and payment to: Kane County Clerk, 719 S. Batavia Ave. Bldg. B
                                  Geneva, IL 60134

				
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posted:7/15/2011
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