Fillable Birth & Death Certificate Application (Stark County Government)

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Birth & Death Certificate Application (Stark County Government)

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The Birth & Death Certificate Application (Stark County Government) form is 1 page long and contains:

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  • 13 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Stark County Government

BROWSE STARK COUNTY GOVERNMENT (OH) FORMS

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Mail application and check to:
Stark County Health Department
7235 Whipple Ave., NW, Ste. B, North Canton, OH 44720
Phone number - 330.493.9904
Birth Certificate $25.00 per
certified copy
Death Certificate
$25.00 per certified copy
Burial / Cremation Permit
$3.00
BIRTH CERTIFICATE REQUEST (Information about the person on the requested record)
Full Name (indicate child’s full name at birth/adoption):
Date of Birth
State of Birth
File Date of Certificate (staff only)
□ Mother
□ Father
□ Parent
parent’s first, full middle, maiden/last
names (state/country of birth)
□ Mother
□ Father
□ Parent
parent’s first, full middle, maiden/last names
(state/country of birth)
DEATH CERTIFICATE REQUEST
Date of Death:
Full Name at Death:
Number of death record copies:
______ x $25.00 = $___________
Place of Death
Township/City of Place of Death
Nursing Home/Hospital Name
(if applicable)
I am requesting a copy with the SSN included because I am:
□The deceased’s spouse, or lineal descendant
□ The deceased’s executor, attorney, or legal agent
□ A representative of an investigative government agency
□ A private investigator
□ A funeral director (or agent responsible for disposition of the
body) acting on behalf of the deceased’s family
□ A veteran’s service officer
□ An accredited member of the media
You must attach a copy of your identification showing you
are an authorized requestor.
Total Amount Due:
$_________________________
APPLICANT INFORMATION (Information about the person requesting the record)
Applicant Name:
Email:
Street Address:
Phone Number:
City, State, & ZIP:
Signature of
Applicant:
FOR OFFICE USE ONLY:
Date:
Check Number:
Staff Name/Initials:
Credit:
Audit Number:
Cash:
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Birth & Death Certificate Application (Stark County Government)

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Completed 14 February 2021

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