Ohio Department of Health Vital Statistics Registration of Birth Application, Finding and Order for Registration of Birth MUST BE TYPEWRITTEN DO NOT FOLD ALL FACTS MUST BE GIVEN AS OF TIME OF BIRTH Case No. Doc. Page OHIO In the Probate Court of _________________________________________________County, on the _________________________ day of ______________________________, 20_____, appeared _______________________________________________ Name of Registrant praying that the facts of birth be established in accordance with section 3705.15 of the revised code as follows: Full Name (at time of birth) Social Security No. Exact Place of Birth Date of Birth Child U Male U Female Name of Father Maiden Name of Mother Age of Father a(t time of this birt) h Age of Mother (at time of this birth) Father Birthplace of Father Mother Birthplace of Mother The following evidence is presented to the court to support abthe ove facts of the place and date of birth and the parentage of the registrant to wit: Document or name of witness Date of Place of birth Date of birth Fathers name Mothers maiden name Record The undersigned being first duly sworn, says that the facts stated in the foregoing Application are true as he/she verily bves and elie prays that the Court order the correction of said birth record. Registrant or Applicant Address Sworn to before me and signed in my presence by the applicant or registrant aforesaid this _________________ day of _________________________________________ 20 _____. (((SSSEEEAAALLL))) Official Character Journal Entry The Court on consideration of the aforesaid evidence submitted finds and orders that notice of hearing be dispensed we biith anrth d th of applicant be registered in accordance with the facts hereinabove set forth; and that a summary finding and order oft, du the courly certified, be forthwith transmitted to the DirectorHea of lth, at Columbus, Ohio, as provided by law. Judge Jack R. Puffenberger I hereby certify the above is a true copy of the application and entry in the foregoing matter. Judge Jack R. Puffenberger (((SSSEEEAAALLL))) By Deputy Clerk bqqmspcY HEA 2782 ( 3/04) Page 1 of LCPC Form APPLRO B Registration of Birth REV 2/05 American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com>>>> 2 Supporting Affidavits Probate Court, ______________________________________________ County, Ohio AFFIDAVIT OF PHYSICIAN In the matter of (1) ____________________________________ of _____________________________________ The State of Ohio, ____________________________________________________ County: ss. I, ______________________________________________________________, do hereby cert that Iify was the physician in attendance at the birth of the applicant herein, and the fthat acts in the application are true, as I verily believe. Attending Physician P.O. address ______________________________________ Sworn to before me and signed in my presence this ___________________ day of _________________________, 20___. (Official Title) NOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the following afits of two perfidavsons, relatives or non- relatives having personal knowledge of the facts or by clear and convincing documentary evidence or such other evidence as the court deems sufficient. The State of Ohio, ____________________________________________________ County: ss. AFFIDAVIT I, ____________________________________________________________________________, (Age _________ Years) do hereby certify that I have personal knowledge of the facts stated in the and that the facts stated within application, herein are true, as I verily believe. P.O. address ______________________________________ Sworn to before me and signed in my presence this ___________________ day of _________________________, 20___. (Official Title) The State of Ohio, ____________________________________________________ County: ss. AFFIDAVIT I, ____________________________________________________________________________, (Age _________ Years) do hereby certify that I have personal knowledge of the facts stated in the and that the facts stated within application, herein are true, as I verily believe. P.O. address ______________________________________ Sworn to before me and signed in my presence this ___________________ day of _________________________, 20___. (Official Title) HEA 2782 (3/04) Page 2 of LCPC Form APPLROB Registration of Birth REV 2/05 American LegalNet, Inc. www.USCourtForms.com