Division of Vital Records, Oklahoma State Department of Health
1000 Northeast 10th Street, Post Office Box 53551
Oklahoma City, Oklahoma 73152-53551


Facts Concerning This Birth

Full name of child at birth___________________________________________Race_______Sex _____

Date of   Birth__________________________Place of Birth______________________________________,Oklahoma
             (MO)                    (Day)                 (Year)                            (County)                                    (City)

Full Name of Father____________________________________________________________________________

Full Maiden Name of Mother_____________________________________________________________________
Signature of person
making this application______________________________________________________Date_______________
If both parents names are not indicated on the original certificate of birth and a "full copy" is desired it will be necessary to have the
signature of the mother, or the registrant if of legal age, or if certificate is required for "adoption purposes" the signature of the attorney
of record and a statement from him to that effect.
The above signature is by (   ) person himself-herself   (   ) next-of-kin  (  ) authorized agent

Purpose for which this copy is needed
(    ) School   (    )Passport   (    ) Employment   (    ) Adoption   (    ) Other  (Please state)_________________________________

Has copy of this person's birth certificate been received before?  Yes(     )   No(     ) Known (     )

PLEASE PRINT CORRECT MAILING ADDRESS BELOW:                                Number of copies wanted @ $5.00 ___
                                                                                                                                     Fee enclosed $___________
                                                   (Name)                                                                        ENCLOSE A STAMPED
_____________________________________________________         SELF-ADDRESSED ENVELOPE
                                               (Street Address)                                                                WITH THIS APPLICATION
                (City)                                                 (State)                            (Zip)

Request for a search of the records for a birth certificate of any person born in Oklahoma should be submitted on this blank along with the required fee of $5.00. If the birth record is on file, a certified copy will be mailed. The information requested above should be filled in carefully and accurately. It is the minimum needed in the Vital Records office to make a thorough search for any birth records. Send five dollars ($5.00) in cash, money order or check for each copy desired. Cash is sent at sender's risk. Make checks or money orders payable to the State Department of Health.§ A copy required to be submitted to the Veterans Administration or U.S. Commissioner of Pensions, in connection with a claim for military-service-connected benefits may be obtained without fee provided a signed statement is attached which sets forth these facts and requests that the copy be issued without fee. Members of the armed forces and veterans must pay regular fees for copies to be used for all other purposes.