Denver Public Health and Environment Birth and Death Certificates Birth Certificate Print this form, complete it and fax it to 7203377676

Certificate Holder's Name ____________________________________________________________________________   (first middle last) Deceased?  Yes  No   If yes, date & state of death:  Date: ________________ State: __________ Father's Name ____________________________________________________________________________   (first middle last)   Mother's Maiden Name ____________________________________________________________________________   (first middle last)   Date of Birth __________________ County/City __________________________________ State_______ Hospital __________________________________________________________ Male  Female Relationship: Self  Mother   Father  Other ________________________________________ Reason for request __________________________________________________ Number Of Copies _______ Ship Method: Express Courier (additional charges)  Regular Mail Ship To Name _________________________________________________________________________________ Address _________________________________________________________________________________ City __________________________ State ______ Zip ____________Phone__________________ Credit Card: Visa   MasterCard    American Express   Discover Credit Card Number _____________________________________________________ Expires _____________ Cardholder's Signature _____________________________________________________   Date _____________ Applicant's Signature _____________________________________________________   Date _____________ Applicant's Email _________________________    Driver's License # _________________________ Driver's License State: ______   DL Issue Date: ___________   DL Expiration Date: ___________ INCLUDE FRONT OF APPROVED IDENTIFICATION WITH THIS FORM. At least 1 of the following: Photo Driver's License Photo identification Card School, College/University Identification Card US Passport Foreign Passport Alien Registration/Permanent Resident Card Temporary Resident Card Employment Authorization Card US Military Identification Card Tribal Identificaton Card US Certificate of Naturalization Certificate of US Citizenship US Citizenship Identification Card Or at least 2 of the following: Work Identification/Paycheck Stub/W-2 Voter Registration Card Social Security Card DD-214 Motor Vehicle Registration/Title Probation Documents Marriage License Medicaid Card Social Services Card Hospital Birth Worksheet Acknowledgment of Paternity Document Department of Corrections Identification Card Note: When making a copy of your ID to place here, enlarge and lighten it to aid identification. This will reduce the processing time for your order.