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Get ID Vital Statistics Certificate Request 2016

Rm are 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 (DAYTIME) ZIP CODE YOUR RELATIONSHIP TO THE PERSON NAMED ON THE CERTIFICATE (SELF, MOTHER, ETC.)  PURPOSE FOR THE CERTIFICATE INCLUDE COPY OF ACKN.

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