1 Ohio Department of Health Registrar’s No. VITAL STATISTICS CERTIFICATE OF ADOPTION INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. Birth No. 134 - (Enter all information CHILD’S PERSONAL DATA below item captions) 1. NAME OF CHILD BEFORE ADOPTION 3. 2. PLACE OF BIRTH (City or village, county, state) NAME OF CHILD AFTER ADOPTION 4. DATE OF BIRTH (Month, Day, Year) 5. SEX ADOPTIVE PARENT(S)’ PERSONAL DATA The following information is to be given as of date of child’s birth entered in Item 4. Relation to child – (Check one) FATHER Adoptive Father Relation to child – (Check one) Natural Father MOTHER Adoptive Mother Natural Mother FATHER’S NAME (First, Middle, Last) MOTHER’S NAME (First, Middle, Last) DATE OF BIRTH (Month, Day, Year) BIRTHPLACE (State or foreign Country) DATE OF BIRTH (Month, Day, Year) BIRTHPLACE (State or foreign Country) RACE (Specify – American Indian, Black, White, etc.) ORIGIN OR DECENT (Italian, Mexican, German, English, Cuban, Puerto Rican, etc. – Specify) RACE (Specify – American Indian, Black, White, etc.) ORIGIN OR DECENT (Italian, Mexican, German, English, Cuban, Puerto Rican, etc. – Specify) OF HISPANIC ORIGIN? EDUCATION (Specify only highest grade completed) Elementary/Secondary School (0-12) College (1-4, 5+) YES OF HISPANIC ORIGIN? EDUCATION NO (If yes – specify Cuban, Mexican, Puerto Rican, etc.) (Specify only highest grade completed) Elementary/Secondary School (0-12) College (1-4, 5+) OCCUPATION AND BUSINESS/INDUSTRY Occupation Business/Industry YES NO (If yes –specify Cuban, Mexican, Puerto Rican, etc.) OCCUPATION AND BUSINESS/INDUSTRY Occupation Business/Industry MOTHER’S RESIDENCE AS OF DATE IN ITEM 4 (Street and Number) OTHER REQUIRED INFORMATION (From original birth certificate) ATTENDANT’S NAME (City, Town, or Location, County, State, Zip) MAILING ADDRESS (Street or R.F.D. No., City or Village, State, Zip) PREGNANCY HISTORY (Complete each Section) Previous pregnancies and adoptions by this mother. (NOTE – include only older children and pregnancies terminated prior to the birth of this child.) M.D D.O C.N.M Below) REGISTRAR’S NAME OTHER TERMINATIONS (Spontaneous and Induced) Before 20 weeks 20 weeks or later Number Number Number None Other (Specify LIVE BIRTHS (Do not include this Child) Now living Now Dead Number Other Midwife None None None DATE OF LAST LIVE BIRTH (Month, Year) DATE FILED BY REGISTRAR (Month, Day, Year) DATE OF LAST OTHER TERMINATION (Month, Year) PARENT’S PRESENT MAILING ADDRESS (Street or R.F.D. No.) (City or Village) (State) (Zip Code) ATTORNEY’S NAME AND ADDRESS (Street or R.F.D. No.) (City or Village) (State) (Zip Code) CERTIFICATION PROBATE COURT, LAKE COUNTY, OHIO. I hereby certify that the child named about was adopted on _____________________ by ________________________________________________ _________________________________as forth in the final decree of adoption, Case No.__________________. Date ________________________ _________________________________________ Probate Judge HEA 2757 (Rev. 3/96) By __________________________________ Deputy Clerk 5335.06 American LegalNet, Inc. www.FormsWorkFlow.com