Blank certificate of live birth form, certified 2021

SACRAMENTO COUNTY¶

SACRAMENTO, CALIFORNIA¶

CERTIFICATE OF LIVE BIRTH¶

STATE BIRTH CERTIFICATE NUMBER STATE OF CALIFORNIA LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMBER¶

THIS CHILD¶

	1A. NAME OF CHILD—FIRST	1B. MIDDLE	1C. LAST
2. SEX Female	3A. THIS BIRTH, SINGLE, TWIN	3B. IF MULTIPLE, THIS CHILD ETC.	4A. DATE OF BIRTH—MONTH, DAY, YEAR

PLACE OF BIRTH¶

	5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY	5B. STREET ADDRESS (STREET, NUMBER, OR LOCATION)
	5C. CITY OR TOWN	5D. COUNTY

FATHER OF CHILD¶

6A. NAME OF FATHER—FIRST	6B. MIDDLE	6C. LAST	7. STATE OF BIRTH	8. AGE OF FATHER
	9A. NAME OF MOTHER—FIRST	9B. MIDDLE	9C. LAST (BIRTH NAME)	10. STATE OF BIRTH

PARENT’S CERTIFICATION¶

I CERTIFY THAT I HAVE REVIEWED THE STATES INFORMATION AND THAT IT IS TRUE AND CORRECT TO THE REST OF MY KNOWLEDGE	12A. PARENT OR OTHER INFORMANT—SIGNATURE	12B. RELATIONSHIP TO CHILD	12C. DATE Signed
I CERTIFY THAT I ATTENDED THIS BIRTH AND THAT THE CHILD WAS BORN ALIVE AT THE HOUR, DATE AND PLACE STATED	12A. PRESENT OR OTHER ATTENDENT—SIGNATURE—DEGREE OR TITLE	13B. LICENSE NUMBER	13C. DATE Signed

ATTENDANT’S CERTIFICATION¶

T4.	13D. TYPED NAME AND ADDRESS
	Wm. Miller, M.D. - #1 Scripps Drive, Sacto. CA

LOCAL REGISTRAR¶

| 15. DEATH—ENTER DATE OF DEATH | 16. LOCAL REGISTRAR—SIGNATURE | 17. DATE ACCEPTED FOR REGISTRATION |¶

GOVERNMENT¶

EXHIBIT¶

14¶

S2 20 Cr. 330 (AJN)¶

CERTIFIED COPY OF VITAL RECORD¶

STATE OF CALIFORNIA, COUNTY OF SACRAMENTO¶

THE GREAT SEAL OF THE STATE OF CALIFORNIA¶

EUREKA¶

This is a true and exact reproduction of the document officially registered and placed on file in the office of the Sacramento County Clerk/Recorder.¶

DATE ISSUED:¶

• 0 0 2 0 0 6 3 5 4 *

OCT 06 2021¶

Alana Olverd¶

GONNA ALLREED, COUNTY CLERK/REGORDER¶

SACRAMENTO COUNTY, CALIFORNIA¶

This copy is not valid unless prepared on an engraved border displaying the date, seal and signature of the County Clerk/Recordant.¶

COUNTY OF SACRAMENTO California¶

EFTA00088946¶