Application for Certified Birth Certificate

Fairfield County Health Dept–VS
1550 Sheridan Drive, Suite 100
Lancaster, OH 43130
(740) 652-2800 option 2
NO REFUNDS WILL BE ISSUED

$32/copy (card fees apply)

Applicant
(your name)

Phone
Number

Full
Address

Birth Certificate Request – Ohio Births Only

Name at birth (or name after legal adoption / court name change — NOT by marriage)

First

Middle

Last

Date of birth (M/D/YY)

Parent names

Mother's full name

Mother's maiden name

Father's full name

Purpose of request and number of copies

Indicate below ONLY IF requesting the record for any of the following purposes:

Dual citizenship in US and a foreign country International marriage or international legal proceedings Genealogy (ex. family tree) research

Number of copies requested

$32 per certified copy (card fees apply). Mail or drop off this application with payment to the address above, or order online at the Vital Statistics page. Birth and death certificates cannot be emailed.