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Get MD Health Birth Form 2012

Hospital: ____________________ Certificate No. (if known) __________ Place of Birth: ________________________ (County or Baltimore City) Full Maiden Name of Mother: ______________________________________________________________________________ Full Name of Father: _______________________________________________________________________ ORDER INFORMATION Number of certificates requested Fee per copy* Amount enclosed x $24.00 A non–refundable $24 fee is required for each copy of a certifica.

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