210065211 Vital Records Authorization Form
Alameda County Recorder
P.O. Box 222130
El Paso, TX 79913-5130
Instructions:
1. Verify that all information below is correct.
2. Print and complete this form. VitalChek Order Number:
3. Sign and date the form (If notarization section is included 210065211
below, signature must occur in the presence of a Notary Public.)
4. Fax the signed form to (866)-233-5149.
Sworn Statement
I, __________________________________ swear/affirm under penalty of perjury under the laws of the State
of California, that I am an authorized person, as defined in the California Health and Safety Code Section
103526(c) , and am eligible to receive a certified copy of the birth, death or marriage record of the following
individual(s).
Name of Person Listed on Certificate Relationship to Person Listed on Certificate
Birth - Authorized : Dearbrea Jones Self
Sworn on ________ / ________/ 20____ at __________________________
, _______.
(Month) (Day) (Year) (City) (State)
____________________________________
Signature
Note: If submitting your order online or by fax and requesting an Authorized Birth, Death or Marriage Certificate, you must have
your Sworn Statement notarized using the Certificate of Acknowledgment, below.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------
A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of
that document.
Certificate of Acknowledgment
State of )
) ss
County of )
On _____________, before me, , NOTARY PUBLIC , personally
(insert name and title of officer)
appeared, , who proved to me on the basis of
(insert name of person signing)
satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted,
executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
Witness my hand and official seal
(NOTARY SEAL)
_______________________________________
Notary Signature