Application for Registration of Birth - Fairfield County Court of Common Pleas

State File No. Case File No. County for probate court Day Month Year Appeared applicant name Full name at time of birth City and County of birth Date of birth

Sex

Male Female

Name of Parent Mother before first marriage Name of Parent Father before first marriage Age of Parent Mother at time of birth Age of Parent Father at time of birth Birthplace of Parent Mother Birthplace of Parent Father Evidence row 1 document or witness Evidence row 1 record date Evidence row 1 documented place of birth Evidence row 1 birth date Evidence row 1 parent name one Evidence row 1 parent name two Evidence row 2 document or witness Evidence row 2 record date Evidence row 2 documented place of birth Evidence row 2 birth date Evidence row 2 parent name one Evidence row 2 parent name two Evidence row 3 document or witness Evidence row 3 record date Evidence row 3 documented place of birth Evidence row 3 birth date Evidence row 3 parent name one Evidence row 3 parent name two Evidence row 4 document or witness Evidence row 4 record date Evidence row 4 documented place of birth Evidence row 4 birth date Evidence row 4 parent name one Evidence row 4 parent name two Registrant or Applicant Address Sworn day Sworn month Sworn year Official Character Probate Judge order signature Probate Judge certified copy signature Deputy Clerk

In the Matter of the Registration of Birth of County for affidavit of physician Name of Physician Mailing Address of Physician Physician affidavit sworn day Physician affidavit sworn month Physician affidavit sworn year Official Title for physician affidavit County for affidavit witness one Name of Witness one Age of witness one Mailing Address of Affiant one Witness one sworn day Witness one sworn month Witness one sworn year Official Title for witness one