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Get Long Branch Vital Statistics

Reet Address (No PO Boxes) Payment Type: Payment Amount: Telephone Number Reason Record is Requested Date of Application Processed By: City State Zip Code Signature B I R T H # 1 Full Name of Child at Time of Birth(First, Middle, Last) Exact Date of Birth Mother s Full Maiden Name(First & Last) No. of Copies Requested If Child s Name Was Changed, Indicate New Name and How It Was Changed Father s Name (If recorded on the record) Purchaser s Relationship to Person Named On.

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