Ohio Department of Health VITAL STATISTICS INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. Registrar’s No. _________________ CERTIFICATE OF ADOPTION Birth No. 134- _________________ (Enter all information below item captions) CHILD’S PERSONAL DATA 1. NAME OF CHILD BEFORE ADOPTION 2. NAME OF CHILD AFTER ADOPTION 3. PLACE OF BIRTH (City or village, county, state) 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. Relationship to Child – (Check one) FATHER  Adoptive Father FATHER’S NAME (First, Middle, Last) Relationship to Child – (Check one) MOTHER Natural Father  Natural Mother Adoptive Mother 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 DESCENT (Italian, Mexican, German, English, Cuban, Puerto Rican, etc. – Specify) RACE (Specify – American Indian, Black, White, etc.) ORIGIN OR DESCENT (Italian, Mexican, German, English, Cuban, Puerto Rican, etc. – Specify) EDUCATION (Specify only highest grade completed) Elementary/Secondary (0-12) College (1-4 or 5+) OF HISPANIC ORIGIN EDUCATION (Specify only highest grade completed) Elementary/Secondary (0-12) College (1-4 or 5+) Yes No (If yes-Specify Cuban, Mexican, Puerto Rican, etc.) OCCUPATION AND BUSINESS / INDUSTRY Occupation Business / Industry OF HISPANIC ORIGIN   Yes No (If yes-Specify Cuban, Mexican, Puerto Rican, etc.) OCCUPATION AND BUSINESS / INDUSTRY Occupation Business / Industry OTHER REQUIRED INFORMATION MOTHER’S RESIDENCE AS OF DATE IN ITEM 4 (Street and Number) (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.) LIVE BIRTHS OTHER TERMINATIONS (Do not include this child) (Spontaneous and induced) Now dead Before 20 weeks 20 weeks and after Now Living Number________ Number________ Number________ Number________ M.D. D.O. C.N.M. Other Midwife Other (Specify Below) REGISTRAR’S NAME None DATE FILED BY REGISTRAR (Month, Day, Year) DATE OF LAST LIVE BIRTH (Month, Year) None None None 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, LUCAS COUNTY, OHIO I hereby certify that the child named above was adopted on ________________________________________ (date) by ____________________________________________________________________________________________ (name(s) of petitioner(s)) as set forth in the final decree of adoption, Case No., _____________________________ Date ____________________________________ By HEA 2757 (rev. 1/89 ______________________________________________ Judge Jack R. Puffenberger ______________________________________________ Deputy Clerk LCPC FORM 20.18 LCPC REVISION 04/07/2005 American LegalNet, Inc. www.USCourtForms.com