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DOH/CHS 023b February 2012 Washington State Department of Health Affidavit for Correction This is a legal Document. Complete in ink and do not alter Center for Health Statistics P O Box 47814 Olympia, WA 98504-7814 (360)236-4300 STATE OFFICE USE ONLY State File Number Fee Number Initials Date Affidavit Number Use the section below for requesting any changes on the record. Record Type: £ Birth £Death £ Marriage £ Dissolution 1. Name on record: 2. Date of Event: 3. Place of Event: (City or County) 4. Father ¶s Full Name (For Birth): (Husband for Marriage or Dissolution) 5. Mother ¶s Full Name (For Birth): (Wife for Marriage or Dissolution) The Record is Incorrect or Incomplete as follows: The Record now shows: The True fact is: 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 16. I represent the person as: £ Self £ Parent £ Guardian £ Informant £ Funeral Director £ Other (Specify) Telephone Number: I declare under penalty of perjury under the laws of the State of Washington that the forgoing is true & correct. 17. Signature: 18. Date: 19. Address