Free affidavit of identity 45
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COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC HEALTH
VITAL RECORDS OFFICE
313 N. FIGUEROA ST. L-1, LOS ANGELES, CALIFORNIA 90012
Birth: (213) 288-7812 / Death: (213) 288-7816

CERTIFICATE OF IDENTITY/SWORN STATEMENT - BIRTH & DEATH
In accordance with California State Law, the following identifying information is required to obtain a certified copy of Birth or
Death Certificate. You must be one of the following to receive an authorized copy of a birth or death record, individual named on
certificate, parent, child, legal guardian/custodian, grandparents, grandchild, sibling, spouse/domestic partner, attorney for
individual/estate of individual or representative of an adoption agency (birth only), funeral director or agent/employee (death
only).

This certificate must be signed in the presence of a Notary.
Applicant’s Relationship to Name(s) Listed on
Certificate

Name(s) Listed on Certificate

I, __________________________________________________, declare under penalty of perjury under the