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APPLICATION FOR
CERTIFIED COPY OF VITAL RECORD
PASQUOTANK COUNTY, NC DEATH
CERTIFICATE DECEASED
NAME _______________________________________DATE OF
DEATH_____________ _________
MARRIAGE
LICENSE GROOM’S
NAME ________________________________________DATE OF
MARRIAGE__________________ BRIDE’S
MAIDEN NAME __________________________________________
FEE: $10.00 BIRTH
CERTIFICATE NAME
________________________________________________DATE OF
BIRTH________________________ FATHER’S NAME ________________________________________________
MOTHER’S MAIDEN NAME ________________________________________________ FEE: $10.00 - Full size with raised seal
THE CERTIFIED COPY OF THE
OF THE ABOVE RECORD IS BEING OBTAINED FOR MY: (ONE OF THE FOLLOWING) 1.
SELF 9. AUTHORIZED AGENT, ATTORNEY 2.
BROTHER OR LEGAL REPRESENTATIVE OF THE 3.
SPOUSE ABOVE NAMED 4.
SISTER 5.
CHILD/STEP-CHILD
10. I AM SEEKING INFORMATION FOR
6.
PARENT/STEP-PARENT LEGAL DETERMINATION OF 7.
GRANDCHILD/STEP-GRANDCHILD PROPERTY RIGHTS 8.
GRANDPARENT/STEP-GRANDPARENT DATE:________________________ SIGNATURE OF APPLICANT
_____________________________________ ________________________________________ PHONE NUMBER __________________________________ PRINTED SIGNATURE
ADDRESS
__________________________________________________________ __________________________________________________________ Pasquotank County, Register of Deeds P. O. Box 154 Elizabeth city, NC 27907-0154 |