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Birth DeathOrderingPacket

The document is an application for a certified copy of a birth or death certificate to be mailed to the Bureau of Vital Records and Statistics in New Orleans, LA. It details the fees for copies requested, applicant information, and necessary documentation required for the application. Additionally, it includes a warning about the consequences of providing false information on the application.

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kandorlogitech1
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14 views1 page

Birth DeathOrderingPacket

The document is an application for a certified copy of a birth or death certificate to be mailed to the Bureau of Vital Records and Statistics in New Orleans, LA. It details the fees for copies requested, applicant information, and necessary documentation required for the application. Additionally, it includes a warning about the consequences of providing false information on the application.

Uploaded by

kandorlogitech1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Mail completed application to:

Bureau of Vital Records and Statistics


P.O. Box 60630
Bureau of Vital Records and Statistics New Orleans, LA 70160

APPLICATION FOR CERTIFIED COPY OF BIRTH/DEATH CERTIFICATE


Birth Certificate Number of Copies Requested: 3 $15.00 each $45.00
Birth Certificate
+ Birth Card (sold as pair only) Number of Pairs Requested: 0 $24.00 $0.00

Death Certificate Number of Copies Requested: 0 $7.00 each $0.00


Check for Fetal Death (stillborn) Certificate $45.00
SUBTOTAL
Mail orders add $0.50 state charge per transaction (no coins) $1.50
If no record is found, you will be notified and fees
will be retained for the search per R.S. 40:40 TOTAL FEES DUE $46.50

ALL MAIL ORDER PAYMENTS MUST BE CHECK OR MONEY ORDER ONLY - Payable to LOUISIANA VITAL RECORDS

Record Information 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.
Name at Birth/Death
First Thomas Middle Williams Last Carvajal
Date of Birth/Death 11/03/1967 Sex M
City of Birth/Death N/A Parish of Birth/Death N/A

Father's Name
First John Middle Loren Last Carvajal

Mother's Full Maiden Name before Marriage


First Margie Middle Ellen Maiden Carter

Relationship to Person Named on the Certificate (must submit photo ID)


Self Father Grandparent Sister Legal Guardian (with judgement of custody)
Mother Child Grandchild Brother Current Spouse Other (specify):

Applicant Information
First Name Thomas Last Name Carvajal Day Phone +1(213) 259-7370
Residence Address 5360 San Vicente Blvd City Los Angeles State CA
Email tomcarvajaljr@gmail.com ZIP Code 90019

Mailing Address for Certificates


Office Use Only

Name Thomas Carvajal


Address 5360 San Vicente Blvd
City Los Angeles State CA
ZIP 90019

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.
Signature VR Form S1 Rev 7/16

Order will be returned if items not completed Signed Copy of Federal or


and included: Correct fees
application State photo ID

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