COUNTY OF SAN DIEGO ERNEST J. DRONENBURG, JR. ASSESSOR/RECORDER/COUNTY CLERK APPLICATION FOR BIRTH/DEATH RECORD SEARCH IN PERSON $19.00 - BIRTH CERTIFICATE $12.00 - DEATH CERTIFICATE FEES ARE NON-REFUNDABLE Effective July 1, 2003, California State Law, Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified copies of birth/death records. Those who are not authorized by law to receive a certified copy will receive a certified copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate below whether you would like a Certified Copy or a certified Informational Copy.  I would like a Certified copy of the record identified on the application form. (In order to receive a Certified Copy, you must indicate your relationship to the person named on the application form by selecting from the list below.) I am:        I would like a certified Informational Copy of the record identified on the application form. (You are not required to select from the list below or complete the Statement of Identity in order to receive an Informational Copy.) The registrant (person named on certificate) or a parent or legal guardian of the registrant. A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the birth record in order to comply with the requirement of Section 3140 or 7603 of the Family Code. A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business. A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant. An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate. Any funeral director who orders certified copies of a death certificate on behalf of any individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section 7100. BIRTH INFORMATION (PLEASE PRINT OR TYPE) - $19.00 for each certified copy Name on Certificate – First Name Middle Name Last Name Date of Birth County of Birth Mother’s Full Maiden Name No. of Copies DEATH INFORMATION (PLEASE PRINT OR TYPE) - $12.00 for each certified copy Name of Decedent – First Name Middle Name Last Name Date of Death County of Death No. of Copies STATEMENT OF IDENTITY FOR AUTHORIZED PERSON I, ____________________________________________, swear under penalty of perjury that I am an authorized person, as (Print Name) indicated above, and am eligible to receive a certified copy of the birth/death record identified on this application form. Sworn this ________day of_______________, 20______, at ______________________________________, ____________ (Day) (Month) (City) (State) ________________________________________ Signature (Must be signed in the presence of a County Clerk) Vitals Form #V2 (12/28/2010) American LegalNet, Inc. www.FormsWorkFlow.com