Application for Certified Copy of Certificate of Birth - Tennessee

TENNESSEE DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS
APPLICATION FOR CERTIFIED COPY OF CERTIFICATE OF BIRTH
(La versión en español al reverso de la página)
Date:
Full name on birth certificate:
First Middle Last Name
Has the name ever been changed o t her than by marriage? Yes No
If yes, what was original name?
Date of birth: Sex:
Male or Female
Month Day Year
Place of birth :
City County State
Hospital where birth occurred:
Full name of father:
Full maiden name of mother:
Last name of mother at time of birth:
Next older brother or sister:
Younger:
Signature of person making request:
Relationship:
Purpose of copy:
Telephone number wh ere you may be reached for additional information:
( )
IT IS UNLAWFUL TO WILLFULLY AND KNOWINGLY MAKE ANY FALSE STATEMENT ON THIS APPLICATION.
All items must be completed and appropriate fees attached to process this request. Do not send cash. Send check or money order
payable to: Tennessee Vital Records. In addition, unless this application is notarized, you must send a photocopy of a
government issued ID showing your signature. If you have not received a response within 45 days, please write or call Tennessee
Vital Records at (615) 741-1763.
PH-1654 (rev 11/2008) RDA N/A
FILL OUT BELOW/ DO NOT DETACH
PRINT name and address of person to whom the certified copy is to be mailed. SEND TO:
Name
Address o r Route
City and State Zip Code
Tennessee Vital Records
421 5
th
Avenue North
1
st
floor, Central Services Building
Nashville, TN 37243
Indicate number of each type
of certificate desired and
enclose appropriate fee:
For years 1949-Current:
___ Short form- $8.00
first
copy. Additional copies
of same record
purchased at same time-
$5.00 each.
___ Long form- $15.00
first
copy. Additional Copies
of same record
purchased at the same
time-$5.00 each.
For births before 1949
:
No short form available
___ $15.00
first copy.
Additional copies of
same record purchased
at the same time -$5.00
each.
The above fees are charged
for the search of records and
will not be refunded even if no
record is on file in this office.
A 3-year search is provided
for the initial fee.
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