Application for Birth/Death Certificate - Louisiana

APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH CERTIFICATE
Short-Form Birth Certification Card
Long-Form Birth Certificate
Death Certificate
Number of Copies Requested:
Number of Copies Requested:
Number of Copies Requested:
$9.00 each
$15.00 each
$7.00 each
SUBTOTAL
Mail orders add $0.50 state charge per transaction
(no coins)
TOTAL FEES DUE
Record Information
Name at Birth/Death
First Middle Last
Date of Birth/Death
Sex
Father's Name
Last Middle First
City of Birth/Death Parish of Birth/Death
MaidenMiddle
Mother's Full Maiden Name before Marriage
First
Relationship to Person Named on the Certificate (must submit copy of photo ID - Front AND Back)
Self
Mother
Father
Child
Grandparent
Grandchild
Sister
Brother Current Spouse
Legal Guardian (with judgement of custody)
Other (specify):
Applicant Information
First Name Last Name
Residence Address City
State
ZIP Code
Day Phone
Email
I am aware that any person who willfully and knowingly makes any false statement on an application for a certified copy of a vital record is
subject upon conviction to a fine of not more than $10,000 or imprisonment of not more than five years, or both.
Name
Address
City
ZIP
Mail completed application to:
Center for Records and Statistics
P.O. Box 60630
New Orleans, LA 70160
Signature
Order will be returned if items not completed
and included:
Signed
application
Copy of Federal or State
photo ID (front AND back)
Correct fees
NOTE: Birth records over 100 years old and Death records over 50 years old can be obtained by writing the Secretary of State.
Address: Louisiana State Archives, P.O. Box 94125, Baton Rouge, LA 70804-9125.
If no record is found, you will be notified
and fees will be retained for the search
per R.S. 40:40
Mailing Address for Certificates
Office Use Only
State
Rev 5/12
ALL MAIL ORDER PAYMENTS MUST BE CHECK OR MONEY ORDER ONLY - Payable to LOUISIANA VITAL RECORDS
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Application for Birth/Death Certificate - Louisiana PDF

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