APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
SUSANNE MORRIS
MADISON COUNTY CLERK
103 W. Trinity, Suite 104, Madisonville, Texas 77864
Phone 936/241-6210
BIRTH - $ 23.00 Each
Enter number requested:
_______ Long Form (Madison County Births only)
_______ Short Form ( State of Texas Births)
DEATH
Enter number requested:
______ $ 21.00 First Certified Copy
______ $ 4.00 each additional copy ordered at this time
Payment accepted by Cash, Credit Card, or Money Order payable to Madison County Clerk
( ) I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting The Texas Home Visitation
Program administered by the Office of Early Childhood Coordination of the Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part 1)
Full Name of Person on record: ______________________________________________________________________
First Middle Last name at Birth /Death
Gender (M/F) _____ Date of Birth or Death: ___________________ County of Birth or Death ______________________
Parent 1: ___________________________________________________________________________________
First Middle Maiden Name/Last Name
Parent 2: ____________________________________________________________________________________________
First Middle Maiden Name/Last Name
Purpose for Obtaining the Certificate: ____________________________________________
APPLICANT INFORMATION (Part 2)
Applicant’s Name: ____________________________________________________Telephone#__________________________
Email Address: _______________________________ Relationship to Registrant: __________________________
Applicant’s Mailing Address: __________________________________________________________________________
Number & Street City State Zip
NOTICE: Applicant must be qualified to obtain the record in accordance with Section 181.1, Chapter 25, Texas
Administrative Code, i.e., the registrant or immediate family member either by blood, marriage or adoption, his or her
Legal Guardian his,or her legal agent or representative. Applicant must provide VALID photo identification at the time
application is made for a birth/death certificate. Additional proof may be requested at the discretion of the clerk.
WARNING: It is a felony to falsify information on this document. The penalty for knowingly making a false
statement on this form or for signing a form which contains a false statement is 2 to 10 years imprisonment and a
fine of up to $10,000. (Health and Safety Code, Chapter 195, Sec. 195.003)
________________________________________ __________________________________
Signature of Applicant Today’s Date
OFFICE USE ONLY:
Local Certificate Recorded_____________ Volume _______ Page _______ Date Issued ________________________
Birth Application TVS Remote Cert. #___________ Deputy Initials______________________
I ACCEPT THIS CERTIFIED COPY AS IS AND UNDERSTAND NO REFUND OR EXCHANGE WILL BE GRANTED.
Signed by:
MAIL APPLICANT is required to attach Affiidavit of Personal Knowledge signed in the presence of a Notary Public,
page 2. Application will not be processed without ID and acknowledgment, and a self-addressed, stamped envelope for
return of the certified copy.
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AFFIDAVIT OF PERSONAL KNOWLEDGE (PART 3)
THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
STATE OF TEXAS
COUNTY OF _____________________
Before me on this day appeared ___________________________________________________now residing at
(Applicant’s Name)
_____________________________________________________________________________________________
(Address) (City) (State) (Zip)
who is related to the person named in Part 1 as _________________________________________and who on oath
deposes and says that the contents of this affidavit are true and correct.
The applicant presented the following type and number of identification:______________________________________
Applicant Signature_______________________________________
Sworn to and subscribed before me, this
____day of __________________, 20_____.
(Seal)
Signature of Notary Public
Commission Expires
Typed or Printed Name
Address
City, State and Zip
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