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Birth Certificate Request

2. The City of East Chicago<br> Department of Public and Environmental Health<br> 100 W Chicago Avenue<br> East Chicago, IN 46312

   The City of East Chicago
   Department of Public and Environmental Health
   100 W Chicago Avenue
   East Chicago, IN 46312
4. Warning
   False application altering, mutilating, or counterfeiting Indiana birth certificates is a criminal offense under I.C. 16-1-10-6.

   False application altering, mutilating, or counterfeiting Indiana birth certificates is a criminal offense under I.C. 16-1-10-6.
6. Disclaimer*
   This form submission is NOT an online payment. For more information concerning online payment please refer to the Vital Records F.A.Q. page. This form only serves those who have been born at St. Catherine's hospital.

   This form submission is NOT an online payment. For more information concerning online payment please refer to the Vital Records F.A.Q. page. This form only serves those who have been born at St. Catherine's hospital.
8. Birth records are only issued to the individual named on the record and their parents, guardians, brother, sister, spouse, or children, with a valid <abbr>ID</abbr> and birth certificate. (Indiana Law I.C. 16-1-19-1) You must be at least 18 years of age to apply.

   Birth records are only issued to the individual named on the record and their parents, guardians, brother, sister, spouse, or children, with a valid ID and birth certificate. (Indiana Law I.C. 16-1-19-1) You must be at least 18 years of age to apply.
10. Full Name at Birth
12. Could this birth be recorded under any other name?

    1. Yes
    2. No
14. If so, please give name:
16. Date of Birth
    Date of Birth
17. Age at Last Birthday
19. Place of Birth
21. Full Name of Father
23. Full Name of Mother
25. Purpose for which record is to be used:
27. Relationship to person whose birth record is requested:
29. Electronic Signature Agreement
30. Today's Date
    Today's Date
32. Address of Applicant
34. City
35. State
36. Zip Code
38. Phone Number
40. We do not accept cash payments or personal checks. Please submit your request along with the exact payment in money order or certified check made payable to the East Chicago Health Department. We also accept credit cards. For mail requests, please include a self address stamped envelope and a Xerox copy of identification of your self, such as a driver's license or state <abbr>ID</abbr>. <br><br> We only sell a combo pack (regular size and wallet) for $12.

    We do not accept cash payments or personal checks. Please submit your request along with the exact payment in money order or certified check made payable to the East Chicago Health Department. We also accept credit cards. For mail requests, please include a self address stamped envelope and a Xerox copy of identification of your self, such as a driver's license or state ID.
    
    We only sell a combo pack (regular size and wallet) for $12.
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