Morgan County Health Department

Application for a Certified Birth Certificate

This office has Morgan County records ONLY.

Office Use Only:

Cert #______________________

Please Complete All Items Below This Line Date____________________

1. Full Name at Birth ______________________________________________________

First Middle Last

2. Birthdate: Month__________ Day________ Year________ Age________ Sex_____

3. Birthplace: City_______________________________ County___________________

4. Has this person been adopted? Yes____ No____ 5. Name been legally changed? Yes____ No____

If so, New Name_______________________________

6. Name of Father __________________________________ Birthplace: State________

7. Full Maiden Name of Mother_________________________ Birthplace: State________

8. How are you related to person on line 1?________________ 9. Record to be used for____________

10. Signature____________________________________ Telephone No.____________

11. Address__________________________City_____________State_______Zip______

Type of Certificate	Qty	Price Each	Total Amt	Provide Two Various Copies of ID
Set includes Full & Wallet Size		$12.00		Driver’s License
Protective Vinyl Sleeve for Full		$2.00		State ID
Protective Vinyl Sleeve for Wallet		$2.00		Social Security Card
Total				Work, Military or School ID Any ID with Your Signature on It

Checks or Money Orders should be made payable to: SEND COPIES ONLY

Morgan County Health Department One piece of ID must display current address.

Print name and address of person to whom the certificate is to be mailed:

Name______________________________________________________

Address____________________________________________________

City/State/Zip________________________________________________

Please return this form with the correct fee amount to:

Morgan County Health Department

180 S. Main St., Ste. 252, Martinsville IN 46151