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Get CA VS 24 2019

CDPH - VITAL RECORDS OR LOCAL REGISTRAR 15. DATE ACCEPTED FOR REGISTRATION STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS FORM VS 24 REV. AFFIDAVIT TO AMEND A RECORD STATE FILE NUMBER NO ERASURES WHITEOUTS PHOTOCOPIES OR ALTERATIONS BIRTH DEATH LOCAL REGISTRATION NUMBER FETAL DEATH TYPE OR PRINT CLEARLY IN BLACK INK ONLY THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD PART I INFORMATION TO LOCATE RECORD 1A. NAME FIRST AS IT APPEARS ON ORIGINAL RECORD 2. SEX 1B. MIDDLE 3. DATE OF EVENT MM/DD/CCYY 1C. LAST 4. CITY OF EVENT 6. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD 5. COUNTY OF EVENT STATEMENT OF CORRECTIONS TO BIRTH DEATH OR FETAL DEATH RECORD 8. ITEM NUMBER TO BE CORRECTED 9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL RECORD 10. CORRECTED INFORMATION AS IT SHOULD APPEAR LIST ONE ITEM PER LINE REASON FOR CORRECTION We the undersigned hereby certify under penalty of perjury that we have personal knowledge of the above facts and that the information given above is true and correct. AFFIDAVITS AND SIGNATURES TWO PERSONS MUST SIGN THIS FORM TO BIRTH DEATH OR FETAL STATE/LOCAL REGISTRAR USE ONLY 12A. SIGNATURE OF FIRST PERSON 12B. PRINTED NAME 12C. TITLE/RELATIONSHIP TO PERSON IN PART I 12D. ADDRESS STREET and NUMBER CITY STATE ZIP 12E* DATE SIGNED MM/DD/CCYY 14. 1/16 APPLICATION TO AMEND A RECORD If an acceptable application to amend the record is registered within one year of the date of the event there is no processing fee however there is a fee required for a certified copy. Enclosed is the fee of for a certified copy of the newly amended record. which includes one certified copy. There is a fee for each additional certified copy. Please contact your Local Registrar County Recorder or the State Registrar for the current fees or visit our website at www. cdph. ca*gov* Printed Name of Applicant Mailing Address of Applicant Telephone Number City State ZIP Code GENERAL INFORMATION The original certificate cannot be altered* This amendment becomes a part of the original record so please type or print clearly in black ink only. Please submit original amendment form only. Photocopies of the amendment form will be rejected* Your certified copy will include a copy of the original certificate with a copy of the amendment. The certified copy of the certificate and the attached amendment must remain together for the certified copy to be valid* READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM This form becomes a part of the original record type or print clearly in black ink only. No erasures whiteouts photocopies or alterations allowed* Enter the Local Registration Number in the space provided in the upper right-hand corner of the form* Complete Part I Items 1 7 with the information as it appears on the original certificate. Enter the certificate item number s to be corrected either from the original or subsequent amendment in Part II Item 8. List one item per line. Enter the incorrect information that appears on the original certificate in the line s provided below Item 9.

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