2. Port Arthur Health Department
   ATTN: Vital Statistics, 449 Austin Avenue Port Arthur, Texas, 77640
4. For Service By Mail:

   Submit Check or Money Order Payable to: CITY OF PORT ARTHUR to above address. Please send completed application, Notarized Proof of Identification & Affidavit of Personal Knowledge, and Photocopy of a Valid Identification 

   Costs:

   Certified Birth Certificate Copies are $23.00 per copy*

   Certified Death Certificate Copies are $21.00 per copy*

   *Additional copies $4.00 per copy

6. Online copy of Affidavit for Out-of-Town Applicants
   Please use this link if you live away and are applying for birth/death certificates
10. RECORD INFORMATION
12. 1. Full Name of Person on the Record
13. Last Name
14. First Name
15. Middle Initial
17. 2. Date of Birth /Death
    2. Date of Birth /Death
18. 3. Sex

    1. Male
    2. Female
20. Add'l Death Certificate Identifying Information:
    ONLY Submit this information for Death Certificates
21. Social Security of Deceased

    Please provide the last 4 digits, only.

22. Date of Birth of Deceased
    Date of Birth of Deceased
24. 4. Place of Birth or Death
25. Address
26. City
28. County
29. State
31. 5. Full name of Father
32. Last Name
33. First Name
35. 6. Mother's Full Maiden Name
36. Maiden Last Name
37. First Name
41. Warning:
    The penalty for knowingly making a false statement on this form can be 2-10 years in prison and a fine up to $10,000.
43. APPLICANT INFORMATION
45. 7. Name of Applicant
46. 8. Phone Number
48. 9. Mailing Address
49. City
51. State
52. Zip Code
54. 10. Relationship to Person on Record
    -- Select One --SelfMotherFatherSisterBrotherGrandparentOther

    Please select from list
55. 11. Purpose of Obtaining this Record
    -- Select One --TravelSchoolDriver's License/I.D. CardPassportInsuranceJobPersonal RecordGenealogyOther

    Please select from list
57. Birth records are confidential for 75 years and death for 25 years; therefore, issuance is restricted. Administrative rules require that on restricted records, all identifying information (items 1-6), relationship (item 10), and purpose (item 11) be provided in order to issue the record.
58. Initials
    Please initial to acknowledge statement
60. Signature
61. Date
    Date
62. Identification Number & Type
Leave This Blank:


63. Print Only

* indicates a required field