Post by Admin on Sept 30, 2021 11:45:03 GMT
Department and Vital statistics State of California
Name:_____________________SEX:_________________
Date of Birth:____________________________________
Place of Birth:___________________________________
Registration District: ____________________________
Parents
Father:______________
Mother:_____________
Status of citizenship of parents
Mother:____________________________________
Father:_____________________________________
On Call
DR that delivered: ____________________
Nurse or other medical staff __________
SCMH or other location __________________________________________________
Vital statistics and records department SCHM
I _____________________ Registra of Births and deaths for the SCMH health department do hereby certify that the above particulars have complied from entry in a registra in my custody.
Witness my hands
this __________ day of _________ 20___
Name:_____________________SEX:_________________
Date of Birth:____________________________________
Place of Birth:___________________________________
Registration District: ____________________________
Parents
Father:______________
Mother:_____________
Status of citizenship of parents
Mother:____________________________________
Father:_____________________________________
On Call
DR that delivered: ____________________
Nurse or other medical staff __________
SCMH or other location __________________________________________________
Vital statistics and records department SCHM
I _____________________ Registra of Births and deaths for the SCMH health department do hereby certify that the above particulars have complied from entry in a registra in my custody.
Witness my hands
this __________ day of _________ 20___