Ohio Department of Health 9,7∃/ 67∃7,67,&6 INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. Registrar’s No. _________________ &(57,),&∃7( 2) ∃∋237,21 Birth No. 134- _________________ (Enter all information below item captions) &+,/∋∂6 3(5621∃/ ∋∃7∃ 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 ∃∋237,9( 3∃5(176∂ 3(5621∃/ ∋∃7∃ 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 ͕ Adoptive Mother MOTHER’S MAIDEN NAME (First, Middle, Last) ͕Natural Mother 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 ͕Yes ͕No (If yes-Specify Cuban, Mexican, Puerto Rican, etc.) EDUCATION (Specify only highest grade completed) Elementary/Secondary (0-12) College (1-4 or 5+) 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 MOTHER’S RESIDENCE AS OF DATE IN ITEM 4 (Street and Number) 27+(5 5(48,5(∋ ,1)250∃7,21 (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) &(57,),&∃7,21 352%∃7( &2857 /8&∃6 &2817