2. First Name*
3. Last Name*
5. Would you like to review records in person, or would you like your own copy? A fee may apply for hard copy requests depending on the size.*
   -- Select One --Review In PersonReceive Copy (Will Pick Up)Receive Copy - EmailReceive Copy - Traditional MailReceive Copy - Fax
6. Phone Number*
   Please provide a contact number in case we have questions about your request, or to notify you the request has been completed.
8. Address1 (optional)
   If you would like records to be mailed to you, please provide a mailing address.
10. City
11. State
12. Zip
14. Email or Fax Number (optional)
    If you would like to receive records by email or fax, please tell us where to send them.
16. Your Request*

    Please describe the records being requested. If you need a BIRTH or DEATH CERTIFICATE, please call the Health Department at 419-468-1075.

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18. 1. Receive an email copy of this form.
19. Email address

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20. Submit

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