Application 
Jefferson County Health Department
500 Market street, 7th floor
Steubenville OHIO 43952

TODAY'S DATE __________________

___ BIRTH CERTIFICATE            OR          ______ DEATH CERTIFICATE

___ Number of Certified Copies ($23.00) Legal Document         $_____

Name (at birth or death)____________________________________________

Date (of birth or death)____________________________________________

For Birth: Father's name____________________________________________

           Mother's (maiden) name___________________________________

Print your name_____________________________________________________

Signature___________________________________________________________

Address_____________________________________________________________

Telephone Number____________________________________________________

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