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Get Birth Certificate Order Form For Galion

TIME OF BIRTH: NUMBER OF COPIES: First Middle Place of Birth: Parents Names: Last Date of Birth: Mother s First Name Mother s Maiden Name Father s First Name Father s Last Name Please Print Your Name Here: Your Signature Your Mailing Address City State Zip Today s Date For Office Use Only Receipt # CC REQUEST FOR CERTIFIED DEATH CERTIFICATES Galion City Health Department 113 Harding Way East; Galion, OH 44833 419/468-1075 Ext. 101 REQUEST FOR DEATH.

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