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Get ID Vital Statistics Certificate Request 2011

Re located on the back of this document. Please read these instructions carefully. Failure to do so may cause a significant delay in processing your request. YOUR MAILING ADDRESS INFORMATION (PERSON REQUESTING THE CERTIFICATE) FULL FIRST NAME FULL MIDDLE NAME STREET AND NUMBER (P.O. BOX) FULL LAST NAME CITY, STATE CONTACT PHONE NUMBER (DAY TIME) ZIP CODE YOUR RELATIONSHIP TO PERSON NAMED ON CERTIFICATE (SELF, MOTHER, ETC.) PURPOSE FOR THE CERTIFICATE SIGNATURE OF THE PERSON REQUESTING T.

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