STATE OF NEVADA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

■ BIRTH St. Affidavit No. ..............................................
HEALTH DIVISION—OFFICE OF VITAL RECORDS
■ DEATH St. Certificate No. ...........................................
AFFIDAVITS FOR CORRECTION OF A RECORD Local Registration No. .....................................
1a. FIRST NAME 1b. MIDDLE NAME 1c. LAST NAME

INFORMATION
AS REPORTED 2. SEX 3. DATE OF BIRTH / DEATH 4. PLACE OF OCCURRENCE (City or County)
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE 5. NAME OF FATHER 6. MAIDEN NAME OF MOTHER

7. 8a. 8b.
ITEM FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
NO.

STATEMENT
OF
CORRECTIONS

WHY ARE 9.
CORRECTIONS
NECESSARY?

OATH OF FIRST WITNESS OATH OF SECOND WITNESS

10. I hereby certify that I have personal knowledge of the above facts and that the information given above is true 14. I hereby certify that I have personal knowledge of the above facts and that the information given above is true
and correct. Signature of First Witness: and correct. Signature of Second Witness:

11. AGE OF WITNESS 12. RELATIONSHIP OF WITNESS TO THE PERSON WHOSE RECORD IS BEING AMENDED 15. AGE OF WITNESS 16. RELATIONSHIP OF WITNESS TO THE PERSON WHOSE RECORD IS BEING AMENDED

13. ADDRESS OF WITNESS (Street, City, State, Zip) 17. ADDRESS OF WITNESS (Street, City, State, Zip)

State of ......................................................................................... State of .........................................................................................

County of ..................................................................................... County of .....................................................................................

Signed and sworn to (or affirmed) before me on ................................................... Signed and sworn to (or affirmed) before me on....................................................
Date Date

by ............................................................................................................................................. by ..............................................................................................................................................
Type or print Affiant’s name Type or print Affiant’s name

.................................................................................................................................................. ...................................................................................................................................................
Notary Public Signature Notary Public Signature

(Seal) (Seal)

18. DATE ACCEPTED 20. DOCUMENTATION USED

FOR USE OF
STATE OR LOCAL
REGISTRAR 19. REGISTRAR

PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM

(NSPO Rev. 10-10)
 INSTRUCTIONS

To correct a BIRTH CERTIFICATE, one of the witnesses on the affidavit must be the person whose birth
is registered on the certificate or his/her parent, guardian, or the medical records clerk of the hospital where the
birth occurred.

To correct a DEATH CERTIFICATE, one of the witnesses on the affidavit must be the funeral director, cer-
tifier or informant listed on the certificate.

Signatures of both witnesses must be notarized. The notary is to put a seal and signature to each
witness’s signature.

Signatures of a minor will be questioned. The person should be at least 18 years of age to make a correction.

Please state clearly on each line of No. 7 the item number on the certificate that is to be changed.

Clearly state on line 8b the corrections to be corrected.

Upon completion, the form and a $40.00 fee (includes one copy of the corrected certificate) should be sent to
the Bureau of Health Planning, Statistics and Emergency Response, Office of Vital Records, 4150 Technology Way,
Suite 104, Carson City, Nevada 89706. There the original record will be altered and the affidavit form filed.

The fee for additional certified copies of a birth certificate is $20.00 each, and certified copies of a death
certificate are $20.00 each.

Please make out your cashier’s check or money order to Nevada Vital Records.

Should you have any further questions, please do not hesitate to call the correction clerk at (775) 684-4242.

When correction is completed, the corrected certificate is to be mailed to the following address:

..........................................................................................................................................................................................................................................
Name

..........................................................................................................................................................................................................................................
Street Address or P.O. Box

..........................................................................................................................................................................................................................................
City State Zip Code