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151 West Main Ave. Suite 9
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Name!at!Birth!____________________________________!!Date!of!Birth!______________________________________!
Father’s!Name!____________________________________!Mother’s!Name!____________________________________!
:.&'H*-.,'$+$%&'.*
Deceased!Name!!!_________________________________!!Date!of!Death!!!_____________________________________!
Father’s!Name!!!!!!_________________________________!!Mother’s!Name!____________________________________!
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Groom’s!Name!!__________________________________!!Bride’s!Name!_______________________________________!
Date!of!Marriage!_________________________________!
O&%H*-.,'$+$./*-("0*$9*P@Q=QQ*
I!*check or m().0*o,/.,*$9*required*+(,*"&0S.)'=J*
The!person!named!above!is!my:!!(Please!indicate)!
Self!!!!!!!!_______________! Daughter!!____________! Grandparent!/!Gre atEGrandparent!!______________!
Spouse!!_______________! Son!!!!!!!!!!!!____________! Grandchild!/!GreatEGrandchild! !!!!!!______________!
Father!!!_______________! Brother!!!!!____________! Stepparent! !!!______________!
Mother!_______________! Sister!!!!!!!!!____________! Stepchild! !!!!!!______________!
Or!I!am:!!!(Please!indicate)!
_______!!
Seeking!information!for!legal!purposes! !!!!_______!!An!authorized!agent,!attorney!or!legal!representative!of!above!
I!solemnly!sw e ar !or !af firm!that!all!the!sta tements!conta ine d !in !th e !ab o v e!r eq u e st!a re !tr ue !a n d !co rre c t.!!N .C . !G en e ra l!S tat u te! #!130AE 93!and!99.!
______________________________________!
Signature!of!Applicant! !
______________________________________!
PO!Box/!Street!Address! !
______________________________________!
City,!State,!and!Zip!Code!
__________________________________________!
Printed!Name!of!Applicant!
(__________)_______________________________!
Complete!10 digit!Daytime!Phone!Number!
A photo copy of your state issued photo ID is
required. Your application will not be processed
without a copy of your state ID.!
______________________________________!
Date!! ! G2T<4*UR23!
A self-addressed stamped envelope is required
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