PLEASE PRINT CLEARLY
FEES ARE NOT REFUNDED AND NOT TRANSFERABLE
FOR ANY RECORD SEARCHED AND NOT FOUND.
(TAC181.22)
X ________________
APPLICATION FOR
BIRTH OR DEATH CERTIFICATE
APPLICANT (YOUR) INFORMATION AND SHIPPING ADDRESS (PLEASE PRINT CLEARLY)
YOUR FIRST NAME
YOUR LAST NAME
YOUR PHONE #
YOUR ADDRESS
CITY
STATE
WHAT IS YOUR RELATIONSHIP TO THE PERSON NAMED ON THE CERTIFICATE? (YOU MUST PROVIDE PROOF OF RELATIONSHIP)
IT’S ME (SELF) I’M A PARENT I’M A SON/DAUGHTER I’M A CURRENT SPOUSE I’M A SIBLING I’M A GRANDPARENT
OTHER_______________________________
REASON FOR REQUEST:
NEWBORN
TRAVEL/PASSPORT
SCHOOL
INSURANCE
RECORDS
OTHER ___________________________
INFORMATION FOR PERSON NAMED ON CERTIFICATE (PLEASE PRINT CLEARLY)
FIRST NAME
MIDDLE NAME
LAST NAME (MAIDEN)
SEX
MALE
FEMALE
DATE OF BIRTH
PLACE OF BIRTH
MONTH
DAY
YEAR
CITY
COUNTY
STATE
HOSPITAL NAME or LOCATION
TEXAS
ONLY
PARENT 1
NAME
FIRST
MIDDLE
LAST (MAIDEN)
PARENT 2
NAME
FIRST
MIDDLE
LAST (MAIDEN)
DATE OF DEATH
PLACE OF DEATH
MONTH
DAY
YEAR
CITY
COUNTY
STATE
HOSPITAL NAME OR ADDRESS OF LOCATION OF DEATH
DALLAS
ONLY
TEXAS
ONLY
HAS RECORD EVER BEEN AMENDED OR CHANGED? NO YES IF YES, WHAT CHANGED? ______________________________________
WARNING: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing a form which
contains a false statement is 2-10 years imprisonment and a fine of up to $10,000. (Health and Safety Code, CHAPTER 195, SEC 195.003)
READ & SIGN: If the record is not found with the information I provided, the FEES ARE NOT REFUNDABLE and are kept.
APPLICANT
SIGNATURE
DATE
FOR MAIL-IN REQUESTS ONLY: NOTARIZED PROOF OF IDENTIFICATION
STATE OF ___________________________________ COUNTY OF ____________________________ This instrument was acknowledged before me on
________________
by __________________________________________________
(Date) (Name of person acknowledging)
___________________________________________
{STAMP}
(Notary Public’s Signature)
TYPE
QTY
PRICE
TYPE
QTY
PRICE
LONG FORM
BIRTH CERTIFICATE
$23
DEATH
CERTIFICATE
$21
ABSTRACT BIRTH
X ______________
$23
ADDITIONAL DEATH
CERTIFICATE
$4
SHEET
PROTECTOR
$2
MAIL REQUEST
FEE
$1
OFFICE USE ONLY DATE STAMP:
CASHIER: _________________ TIME IN: ________________
PAYMENT TYPE: ___________ AMOUNT DUE: ____________
PROCESSOR: _______________ TIME OUT: _______________
DCN #: ________________________________________________
FILE #: ___________________________________ CE
rev. 07/12/2021
CITY OF DALLAS VITAL STATISTICS
APPLICATION FOR BIRTH OR DEATH CERTIFICATE
Applications for birth or death certificates will not be processed without a photo ID or alternate IDs and the signature of the applicant.
LOCATION: J. Erik Jonsson Central Library, 1
st
Floor, 1515 Young Street, Dallas, TX 75201
HOURS: Monday-Friday 8:30AM 4:30PM PHONE: (214) 670-3092 WEB: dallasvitalstatistics.com EMAIL: vitalinfo@dallascityhall.com
LOCAL REGISTRAR: Margarita A. Carrasco DEPUTY REGISTRAR: Lolita Fuller
ONLINE REQUESTSVisit www.vitalchek.com. Online orders are mailed 1-2 business day after receipt of the request. $10 VitalChek service fee will be
charged on all online orders.
MAIL REQUESTS - Processed and mailed 1-5 business days after receipt of the request. Mail requests without signature, valid photo ID, or notary
signature/stamp will not be processed. For all mail requests, there is an additional $1.00 fee for postage and handling. We accept money orders made
payable to: CITY OF DALLAS. No personal checks please.
LONG FORM BIRTH CERTIFICATE This is the most comprehensive birth record. It is a copy of the original birth certificate. It will also show a history of
corrections that have been made to the birth record. This form is often used for requesting passports. We can only issue long form birth certificates for
births that occurred in the city of Dallas from April 1983 to present.
ABSTRACT BIRTH CERTIFICATEThis is a summary of the birth record. This birth certificate will only show current information for the registrant’s name,
date of birth, place of birth, gender, and name of parent(s). This form will not show a history of corrections. Abstract birth records are available for births that
occurred in the state of Texas from 1926 to present. This birth certificate is often used for school records and is acceptable for most purposes.
DEATH CERTIFICATE - Death records are available only for deaths that occurred in the City of Dallas from April 1983 to present.
VERIFICATION LETTER - A verification letter will include the registrant’s name, the date of event, and the county where the event occurred. Verification
letters are available for births or deaths that have occurred in the City of Dallas since April 1983. Verification letters are not considered legal substitutes for
certified copies of birth certificates. City of Dallas Vital Statistics Unit strongly recommends that applicants ensure a verification will satisfy its intended use
as refunds are not issued. X______________
PROPERLY QUALIFIED APPLICANT - Birth and death certificates can only be issued to a properly qualified applicant. Per Title 25 Texas Administrative
Code Subchapter A 181.1(21,13) A properly qualified applicant is the individual named on the certificate or immediate family member (children, parents,
siblings, grandparents, or current spouses) either by blood, marriage or adoption, legal guardian, or the registrant’s legal agent or representative.
Local, state, and federal law enforcement or governmental agencies and other persons may be designated as properly qualified applicants by demonstrating
a direct and tangible interest in the record. All applicants who are not immediate family members must provide legal documentation such as a
certified court order, birth/marriage certificate, or insurance policy that demonstrates a direct, tangible interest in the record requested.
ACCEPTABLE IDENTIFICATIONPer Title 25 Texas Administrative Code Subchapter B 181.28 (i) 2, 5, 11(a) All applicants must present proof of
identity acceptable to the State Registrar. All applicants must sufficiently identify the vital record that is of interest at the time of request. In the absence of a
form of primary identification, applicants are permitted to submit secondary forms of identification to establish proof of their identity. Ask staff for a complete
list of acceptable identification or visit
https://dshs.texas.gov/vs/reqproc/Acceptable-IDs/
PHOTOCOPY OF YOUR DOCUMENTSPer Title 25 Texas Administrative Code Subchapter B 181.28(e) and (i)8 Prior to the release of any Vital
Statistics information, the Vital Statistics Unit shall retain a photocopy of all documents submitted and accepted as proof of identification for a period of three
years from the date issued.
MAIL REQUEST CHECKLIST
Complete the application; Please type or print clearly
Complete the NOTARIZED PROOF OF IDENTIFICATION section located at the bottom of the application. Be sure to sign and date the application
in the presence of a notary public
Enclose a copy of a current driver's license, United States passport, or United States issued identification
Enclose appropriate fees. Please make cashier checks or money orders payable to: City of Dallas
Mail request to City of Dallas Vital Statistics, 1515 Young Street, Dallas, TX 75201
For the status of your City of Dallas online or mail-in request, please call 214-670-3092 or email vitalinfo@dallascityhall.com
.
FOR OFFICE USE ONLY
CITY OF DALLAS VITAL STATISTICS
Texas Vital Statistics
1100 W. 49
th
St., Austin, TX 78756
1-888-963-7111
vrstatus@dshs.texas.gov
PO Box 12040, Austin, TX 78711-2040
rev. 07/12/2021