Kent City Health Department Online Vital Records Request

Please Enter Child's Full Name:

Last Name: ^{(full name, no initials)}

First Name:

Middle Name:

Information Related to Child's Birth:

Date of Birth:

Confirm Birth Year:

Birth City:

Birth State:

Parent Names as Listed on Birth Certificate:

Mother's Last Name:

Mother's First Name:

Mother's Maiden Name:

Mother's Birth State:

Mother's Birth Country:

Father's Last Name:

Father's First Name:

Father's Birth State:

Father's Birth Country:

Requestor's Contact Telephone Numbers: ^{(###-###-####)}

^Home:

^Cell:

Requestor's Email:

^Address:

^Confirm:

Reason for Request:

Select Reason:

Please select the document delivery method

I will PICK-UP these documents at:

Kent City Health Department
201 E. Erie Street
Kent, OH 44240

I would like my document(s) delivered via MAIL.

I would like priority shipping!

The individual listed on the Birth Certificate is:

My Child / Step-child

Select The Information Type(s) Requested:

Total Fee:

$0

AUTHORIZATION NOTIFICATION:

My initials below constitute an electronic signature and authorizes the Kent City Health Department to release information and / or my vital record and confirms I have completed all sections accurately and truthfully, including information verifying my identity. I understand that the recipient of the record(s) will use the indicated documents(s) for legitimate interests only and that the information contained therein shall not be further transferred or communicated to any other party or agency without my expressed written consent.

I have enclosed the correct fees and understand that they are nonrefundable. I understand that an incomplete form will not be processed and will be considered closed after expiration of the 30 day notification window. I declare under penalty of perjury that the foregoing is true and correct.

Please note the following:

The fee will be paid through Permitium Payments. The charge will show on your credit card statement as 'GovtPermit/Certificat'
An additional Non-Refundable $5 Service + Credit Card Processing Fee will be applied to all online orders

Coupon Code:

Mother's Initials:

Clear Form

Online Birth Certificate Request

Please Enter Child's Full Name:

Information Related to Child's Birth:

Parent Names as Listed on Birth Certificate:

Requestor's Contact Telephone Numbers: ^{(###-###-####)}

Requestor's Email:

Reason for Request:

Documents Will Be Delivered To: ^{please enter the delivery addresses}

The individual listed on the Birth Certificate is:

Select The Information Type(s) Requested:

Total Fee:

$0

Online Birth Certificate Request

Add An Address

A Shipping Address Is Required!

Please Enter Child's Full Name:

Information Related to Child's Birth:

Parent Names as Listed on Birth Certificate:

Requestor's Contact Telephone Numbers: (###-###-####)

Requestor's Email:

Reason for Request:

Documents Will Be Delivered To: please enter the delivery addresses

The individual listed on the Birth Certificate is:

Select The Information Type(s) Requested:

Total Fee:

$0

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Requestor's Contact Telephone Numbers: ^{(###-###-####)}

Documents Will Be Delivered To: ^{please enter the delivery addresses}