SOP 214.03-att-1: Request for a Certified Copy of a Vital Record

Attachment 1

IIA16-0001

(214.03)
04/23/15

# REQUEST FOR A CERTIFIED COPY OF A VITAL RECORD

ONLY COPIES OF VITAL RECORDS REGISTERED IN GEORGIA ARE
AVAILABLE. A separate form must be completed for each type of vital record and
for each person for whom a certified copy of a vital record is requested.
To: Vital Records Branch
DHR 2600 Skyland Drive N.E.
Atlanta, Georgia 30319-3640
# From: Warden/Superintendent ________________________________ ____________________________________________________________ (Warden/Superintendent’s name and mail address entered in this space) Inmate ____________________ EF_____________________

I am requesting a certified copy of a BIRTH DEATH MARRIAGE
certificate
(CIRCLE ONLY ONE TYPE OF CERTIFICATE )
Total number of copies requested____________________
in the name of ________________ SEX_____ RACE___________
DATE the birth, death or marriage occurred_____________________________
Month Day Year
COUNTY where the birth, death or marriage occurred____________________
RELATIONSHIP to person named on the certificate_____________________
For Birth Certificate Search ONLY – Parent’s Names:
Mother’s Maiden Name: ____________________________________________
Father’s Name:____________________________________________________
The following circumstance (s) exist which necessitates that a copy of a vital record as
indicated above be issued:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________ _________________
Inmate’s Signature Date Signed
I hereby authenticate this request for the above record
__________________________________________Approved Disapproved (circle one)
Counselor’s Signature Date Signed
_________________________________________ Approved Disapproved (circle one)
Warden/Superintendent’s Signature Date Signed

Total FEE enclosed: $__________ ($10.00 for the first copy. $5.00 each for additional
copies of the same certificate ordered at the same time.)
_________________________________________
Business Office Signature Date Signed

RETENTION SCHEDULE: A copy of this attachment will be placed in the inmate/probationer administrative/case history
file and will be retained according to the official records retention schedule for that file.