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Nt of Health VITAL STATISTICS CERTIFICATE OF ADOPTION . INFORMATION PROVIDED ON THIS FORM IS TO BE USED TO ESTABLISH A NEW CERTIFICATE OF BIRTH FOR THE ADOPTED CHILD. CHILD'S PERSONAL DATA 1 Name of Child BEFORE Adoption 2 Name of Child AFTER Adoption 3 Place of Birth (City, County, State or Foreign Country) 4 Date of Birth (Month, Day, Year) 5 Sex ADOPTIVE PARENT(S) PERSONAL DATA The following information provided below will be used to create the new birth record. List information as.

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