CHILD'S INFORMATION:

NAME OF CHILD-FIRST ____________________MIDDLE:___________________LAST_____________________

SEX ____ THIS BIRTH WAS SINGLE, TWIN, ETC.: _____ IF MULTIPLE, THIS CHILD 1ST, 2ND, ETC_____________

DATE OF BIRTH____________HOUR OF BIRTH ______PLACE/ADDRESS OF BIRTH:________________________

STREET ADDRESS:______________________ CITY: ___________COUNTY _______________: ZIP CODE: ______

NAME OF FATHER: FIRST _______________ MIDDLE ____________________ LAST_______________________

FATHER'S STATE OF BIRTH: FATHER’S DATE OF BIRTH:

MOTHER'S STATE OF BIRTH MOTHER’S DATE OF BIRTH-

_____________________________________________________________________________________________

CONFIDENTIAL INFORMATION FOR PUBLIC HEALTH USE This is a xeroxed of a portion of the current birth registration form in use for many decades

Line 18 -20C / FATHERS RACE, USUAL OCCUPATION, KIND OF BUSINESS, # YEARS OF EDUCATION,

Line 21 -24E / MOTHER’S RACE, HISPANIC Y/N; USUAL OCCUPATION, KIND OF BUSINESS, YEARS EDUCATION, RESIDENCE - STREET # OR LOCATION, COUNTY, CITY, STATE, ZIP CODE

Lines 25A - 33 / MEDICAL DATA" -- 25a DATE OF LAST MENSES, 25b, MONTH PRENATAL CARE BEGAN, 25c, NUMBER OF VISITS, 25d METHOD OF PAYMENT FOR PRENATAL CARE; 26 BIRTHWEIGHT (IN GRAMS), PREGNANCY HISTORY - LIVE BIRTHS; 27a NOW LIVING, 27b, NOW DEAD ; 27c DATE OF LAST LIVE BIRTH; OTHER TERMINATIONS (EXCLUDING INDUCED ABORTION) 27d, BEFORE 20 WEEKS; 27e AFTER 20 WEEKS; 27f, DATE OF LAST TERMENATION; 28a METHOD OF DELIVERY; 28B METHOD OF PAYMENT FOR DELIVERY

_____________________________________________________________________________________________

AFFIDAVIT:

I solemnly swear of affirm that the information stated above is true and correct to the best of my knowledge and belief. I certify that the child named herein was born alive to the stated mother at the place, date and time shown above.

This form was completed with the udnerstand that the facts so stated herein afford a full, complete and truthful represetatiion of the facts and what my trestamony shall be should I be asked or directed to testify to the facts herein in a court of law. I realize that any false facts/information made herein could subject me to the risk of criminal liability, including but not limited to prosecution for perjury

Mother's printed name _____________________________________ I, the Certified Nurse Midwife/Licensed Midwiwfe (CNM/LM)

further swear that I provided prenatal care to the mother named above.

Mother's written signature ____________________________________ CNM/LM printed name _______________________________

Printed name of witness______________________________________ CNM/LN written signature _____________________________

Witncss’ written signature ____________________________________ Date of signing ______________________________________

Wimess address: ____________________________________________ City & couunty where signed: ___________________________

_________________________________________________________ Date of signing: _____________________________________

Relationship of witness to newborn child: ________________________ Signature of LFLD staff mmber,

Printed name of LRD staff mmber: ______________________________

Date ___________________ Registered ________ Copies of lDs on back ____________ Denied____________________________-

Inventory Control Number Here __________________

Click the pic for additional information