APPLICATION FOR DELAYED RECORD OF BIRTH

Full Name

of Child

Date

Time

Sex

of Birth

of Birth

of Child

Place

of Birth

Hospital

County

City, Village, Township

If not born in hospital, give complete address where child was born

Mother's

Maiden Name

Mother's

Mother's

Date of Birth

Place of Birth

Mother's complete mailing

address at time of child's birth

Street & number or R.F.D.

City or Town

State

Zip

Mother's residence at

time of child's birth

Street & number

City or Town

Yes/No

Inside City

County

State

Father's

Full Name

Father's

Father's

Date of Birth

Place of Birth

Was mother married at the time of conception, birth or anytime between conception and birth?  If yes, date of parent's marriage

List below all OTHER children of this mother who were born BEFORE this child was born.  DO NOT COUNT THIS CHILD

(a)

Number

(b)

Number BORN alive

(c)

Number

still living

but now dead

born dead

Written Signature

Address

My Relationship to Child

8631A