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M:\Data\Personal Health-PH\Administration-AD\AD-1014-VR VITAL RECORDS APPLICATION-00.00-08.08.doc Klickitat County Health Dept. VITAL RECORDS APPLICATION Klickitat County Health Dept. 501 E. Washington St./P.O. Box 159 228 W. Main MS CH-14 White Salmon, WA 98672 WASHINGTON STATE BIRTH CERTIFICATES Goldendale, WA 98620 [PHONE REDACTED] 1-[PHONE REDACTED] [PHONE REDACTED] 1-[PHONE REDACTED] 1907 TO PRESENT COUNTY ISSUED BIRTH CERTIFICATES ARE NOT ACCEPTED BY TRIBAL ENROLLMENT. PLEASE ASK IF YOU NEED FURTHER INFORMATION. DATE # OF COPIES @ $20.00 EACH CASH OR MONEY ORDERS ONLY NO PERSONAL CHECKS DO NOT SEND CASH ARE YOU REQUESING A CERTIFIED COPY IN ORDER TO MAKE CHANGES TO A SOCIAL SECURITY CARD? NO YES PLEASE CONTACT THIS OFFICE BEFORE PROCEEDING. NAME ON RECORD FIRST MIDDLE LAST DATE OF BIRTH MONTH DAY YEAR PLACE OF BIRTH CITY COUNTY HOSPITAL FATHER’S NAME FIRST MIDDLE LAST MOTHER’S MAIDEN NAME FIRST MIDDLE LAST REQUESTOR’S NAME AND ADDRESS REQUIRED NAME DAYTIME PHONE ADDRESS CITY STATE I WILL PICK UP MY CERTIFICATE IN PERSON PLEASE MAIL MY CERTIFICATE TO THE ADDRESS ABOVE FOR OFFICE USE ONLY RECEIVED AMT REC’D MO # DATE MAILED DATE PICKED UP STAFF INITIALS