Application 
Jefferson County Health Department
500 Market street, Basement
Steubenville OHIO 43952

TODAY'S DATE __________________

___ BIRTH CERTIFICATE            OR          ______ DEATH CERTIFICATE

___ Number of Certified Copies ($18.00) Legal Document         $_____

Name (at birth or death)____________________________________________

Date (of birth or death)____________________________________________

City (of birth or death)____________________________________________

Print your name_____________________________________________________

Address_____________________________________________________________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mail Application with money order to the JCHD at the above address

(No personal checks accepted)