DARKE COUNTY HEALTH DEPARTMENT
300 GARST AVENUE
GREENVILLE, OHIO 45331
(937) 548-4196
REQUEST FOR CERTIFIED BIRTH CERTIFICATE
Name at Birth_________________________________________________________________
Date of Birth__________________________________________________________________
Mother’s Maiden Name___________________________________________________________
Father’s Name_________________________________________________________________
Signature of Person Making Application______________________________________________
Date__________Address: _______________________________________________________
Phone Number: ________________________________________________________________
Number Of Copies Requested: __________
**$18.00 per certified copy
**Please include check or money order payable to: Darke County Health Department
**Please include a self addressed stamped envelope for the birth certificate to be mailed back to you.
Page last updated: 1/8/2008