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Birth Certificate

Please enter the required information below.

Price$10.00

Quantity

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Record of Birth Information:Full Name at Birth*

sm_tbcfC150462Full Name at Birth is required.

Date of Birth*?

sm_tbcfC150463Date of Birth is required.

Mother's Maiden Name*

sm_tbcfC150464Mother's Maiden Name is required.

Father's Name*

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Mail To:Requestor's Full Name*

sm_tbcfC150467Requestor's Full Name is required.

Mailing Address*

sm_tbcfC150468Mailing Address is required.

City/Town*

sm_tbcfC150469City/Town is required.

State*

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Zip Code*

sm_tbcfC150471Zip Code is required.

Daytime Phone Number*?

sm_tbcfC150472Daytime Phone Number is required.

Email Address*

sm_tbcfC150473Email Address is required.

Notes:

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