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.

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Page last updated: 1/8/2008