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APPLICATION FOR
CERTIFIED COPY OF VITAL RECORD
PAMLICO COUNTY, NC DEATH
CERTIFICATE DECEASED
NAME _______________________________________DATE OF
DEATH______________________ MARRIAGE
LICENSE GROOM’S
NAME ________________________________________DATE OF
MARRIAGE__________________ BRIDE’S
NAME __________________________________________ BIRTH
CERTIFICATE NAME
________________________________________________DATE OF
BIRTH________________________ FATHER’S
NAME ________________________________MOTHER’S NAME
____________________________ COUNTY
OF BIRTH _____________________________________ FEE: $10.00 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
_____________________________________ ________________________________________ Driver's License/Photo ID # ______________________________ PRINTED SIGNATURE
ADDRESS
__________________________________________________________ FEE : $10.00 __________________________________________________________ PO Box 433, Bayboro, NC 28515 |