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REQUEST FOR CERTIFIED COPY OF BIRTH CERTIFICATE |
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Name:___________________________________________________
Date of Birth:______________________________________________
Birthplace:________________________________________________
Father's Name:_____________________________________________
Mother's First and Maiden Name: ______________________________
Person Requesting This Copy: _________________________________
Date:__________ Signature: X_________________________________
Photo Copy Street,
of I. D. P.O. Box or R. R # _________________________
City: _____________________ State:_______
Tel.#_____________________ Zip:_________
GIBSON COUNTY DEPARTMENT OF HEALTH
800 S. Prince
Princeton, IN 47670
Phone: (812) 385-3831
Fee $10
WARNING: False application, altering, mutilating or counterfeiting
Indiana birth certificates is a criminal offense under I.D. 16-37-112.
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Vital Health Records 
