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Envelope # AFS # Ohio Department of Health VITAL STATISTICS CERTIFICATE OF ADOPTION CHILD'S PERSONAL DATA 1 Name of Child BEFORE Adoption 2 Date of Birth (Month, Day, Year) 3 Sex 4 Place of Birth (City, County, State or Foreign Country) Child's Name After Adoption First Name Middle Name Last Name ADOPTIVE PARENT(S)' PERSONAL DATA The following information provided below will be used to create the new birt.

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