Noble County Health Department
2090 N State Road 9, Suite C
Albion, Indiana 46701
Telephone (260) 636-2191
           Fax (260) 636-2192
Clinic Fax: (260) 636-3753

Warning: False application for, and/or altering, mutilating, or counterfeiting an Indiana Birth 
Certificate  is a criminal offense under IC 16-37-1-12

Application For a Certified Birth Certificate

Identification Required
Photo Copy - Driver's License or State I.D.

Complete all information below:

 1.  Full Name at Birth_________________________________________________________________________________
                                      First                                                Middle                                                              Last

 2.  Name after any legal changes or court ordered paternity:___________________________________________________

 3.  Has this person ever been adopted?     Yes________     No_______

       If YES, give name after adoption here:_________________________________________________________________

 4.  Gender______________ 5. Date of Birth: _____________________________________________ 6. Age:___________

 7.  Place of Birth (Hospital or Home): ____________________________________________________________________

 8.  Full Name of Father: _______________________________________________________________________________

 9.  Mother's maiden name (her birth name) : _______________________________________________________________

10.  If this is not your record, how are you related to person in item No. 1?________________________________________

11. For what purpose will record be used?__________________________ _______________________________________

12. Your signature: _______________________________________________                  Phone number: _______________

13. Your address: ____________________________________________________________________________________
                               Street Address                                                             City                                   State                 Zip

Payable by Cash* or Money Order           No Personal Checks                    *Not responsible for cash sent in mail

Fees: $10.00 per certificate                                                                               Mail to:    

Full Size                                                                                                               Noble County Health Department 
Wallet Size (not laminated)                                                                               2090 N St Road 9 Suite C-2 
                                                                                                                              Albion IN 46701   
For Office Use Only:  ID _____________________________________Receipt #___________________________

Searched by:___________________________________Date:__________________Cert #___________________


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