INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. Ohio Department of Health VITAL STATISTICS CERTIFICATE OF ADOPTION State Use Only Original SFN Amended SFN Envelope # AFS # 1. Name of Child BEFORE Adoption 2. Date of Birth (Month, Day, Year) CHILD'S PERSONAL DATA 3. Sex 4. Place of Birth (City, County, State or Foreign Country) First Name Child's Name After Adoption Middle Name Last Name The following information provided below will be used to create the new birth record. List information as it existed on child's date of birth. Choose One: Mother Father Parent Gender: Female Male Choose One: Mother Father Parent Gender: Female Male Current First Name Current Middle Name Current Last Name Last Name Prior to First Marriage Date of Birth (Month, Day, Year) Birth Place (State or Foreign Country) Current First Name Current Middle Name Current Last Name Last Name Prior to First Marriage Date of Birth (Month, Day, Year) Birth Place (State or Foreign Country) ADOPTIVE PARENT(S)' PERSONAL DATA Parent(s) Residence at Time of Child's Birth (Number and Street) City County State Zip Code Inside City Limits (Yes or No) Other Required Information (From the Original Birth Certificate) Attendant's Name (M.D, D.O, C.N.M, Other Midwife) Mailing Address (Number, Street, City, County, State, Zip Code) Registrar's Name Date Filed by Registrar (Month, Day, Year) Parent(s) Current Mailing Address Attorney's Name and Address Street Street Foreign Adoptions Only (from the Original Birth Certificate) Time of Birth Hospital/Birthing Facility Registrar's Name & Date Filed by Registrar (Month, Day, Year) Attendant's Name (M.D, D.O, C.N.M, Other Midwife) & Date Signed City or Village City or Village State State Zip Code Zip Code CERTIFICATION Probate Court, I hereby certify that the child named above was adopted on By As set forth in the final decree of adoption, Case No., Date Probate Judge Deputy Clerk HEA 2757 Rev. 08/2015 5335.06 American LegalNet, Inc. www.FormsWorkFlow.com County, Ohio (Date) (Name(s) of Petitioner(s))