Patient Identification Sticker
BIRTH CERTIFICATE WORKSHEET
This form will be used to create your baby's official birth certificate. Complete as much of the information as possible,
including full legal names. Return this form along with your pre‐admission paperwork to District One Hospital. If you have
any questions, please contact the Women's Health Unit at 332‐4743. Thank you.
Birth Place (state or foreign country)
Date of Birth:
Do you live inside the city limits?
Social Security Number:
If no, Name of Township:
Education (Highest grade completed) Elem/Secondary (0‐12)
Live Births (do not include this child)
Number of children: living
College (1‐4 or 5+)
Date of last live birth (month, year)