Registrar's No. Ohio Department of Health INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. VITAL STATISTICS Birth No. 134 - CERTIFICATE OF ADOPTION (Enter all information below item captions) CHILD'S PERSONAL DATA 2. NAME OF CHILD AFTER ADOPTION 1. NAME OF CHILD BEFORE ADOPTION 4. DATE OF BIRTH (Month, Day, Year) 3. PLACE OF BIRTH (City or village, county, state) 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. Relation to child - (Check one) FATHER Adoptive Father Relation to child - (Check one) MOTHER Natural Father FATHER*S NAME (First Middle, Last) Acloptrve Mother Natural Mother MOTHER'S MAIDEN 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,Mexcan, German, English, I Cuban, Puerto Rican, etc. - Specify) RACE (Specify-Amencan 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+) EDUCATION (Specify only highest grade completed) College (1-4 or 5+) Elementary / Secondary (0-12) OF HISPANIC ORIGIN? Yes No (if yes - Specify Cuban, Mexican, Puerto Rican. etc.) OCCUPATION AND BUSINESS / INDUSTRY OCCUPATION AND BUSINESS/ INDUSTRY Business / Industry Occupation OF HISPANIC ORIGIN? Yes No (if yes - Specify Cuban. Mexican. Puerto Rican. etc.) Occupation OTHER REQUIRED INFORMATION Business / Industry MOTHER*S RESIDENCE AS OF DATE IN ITEM 4 (Street and Number) (From original birth certificate) (City. Town. or Location, County, State, Zip) ATTENDANTS NAME 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) MAILING ADDRESS (Street or R.F.D. No., City or Village, State, Zip) M.D D.O. C.N.M. Other Midwife OTHER TERMINATIONS (Spontaneous and induced) LIVE BIRTHS (Do not include this Child) Other (Specify Below) Now living I I I I I I I . Number REGISTRAR'S NAME None DATE FILED BY REGISTRAR IMonth, Day, Year) Now dead Before 20 weeks Number Number None None DATE OF LAST LIVE BIRTH (Month. Year) 20 weeks and after Number I 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,SHELBY COUNTY, OHIO. I hereby certify that the child named above was adopted on by (date) (name(s) of petitioner(s)) as set forth in the final decree of adoption, Case No., Date Probate Judge By HEA 2757 (Rev. 3/96) Deputy Clerk 5335.06 American LegalNet, Inc. www.FormsWorkflow.com