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First NameMiddle NameLast Name (Name Given at Birth)
Name of Hospital in PasadenaWas there an adoption, amendment or name change? \\textbf{Yes} \\textbf{No}Sex \\textbf{Female} \\textbf{Male}Date of Birth
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First NameMiddle NameLast Name
Mailing Address (Number, Street)Apt #/UnitTelephone Number ( )
CityStateZIP Code
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"location": { "l": 235.2, "t": 400.08, "r": 367.92, "b": 371.28 }, "text": "Middle Name", "field_kind": "text", "label": "Middle Name", "pdf_field_name": "Middle Name_4", "pdf_field_type": "Text", "reading_order": 27 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 370.2, "t": 400.08, "r": 588.36, "b": 371.28 }, "text": "Last Name", "field_kind": "text", "label": "Last Name", "pdf_field_name": "Last Name", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 19.2, "t": 359.16, "r": 232.92, "b": 330.36 }, "text": "Mailing Address (Number, Street)", "field_kind": "text", "label": "Mailing Address (Number, Street)", "pdf_field_name": "Mailing Address Number Street", "pdf_field_type": "Text", "reading_order": 29 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 235.2, "t": 359.16, "r": 367.92, "b": 330.36 }, "text": "Apt #/Unit", "field_kind": "text", "label": "Apt #/Unit", "pdf_field_name": "Apt Unit", "pdf_field_type": "Text", "reading_order": 30 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 369.84, "t": 358.92, "r": 588.72, "b": 342.36 }, "text": "Telephone Number ( )", "field_kind": "text", "label": "Telephone Number ( )", "pdf_field_name": "Telephone Number", "pdf_field_type": "Text", "reading_order": 31 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 19.08, "t": 319.2, "r": 233.04, "b": 294 }, "text": "City", "field_kind": "text", "label": "City", "pdf_field_name": "City", "pdf_field_type": "Text", "reading_order": 32 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 235.08, "t": 319.2, "r": 368.04, "b": 294 }, "text": "State", "field_kind": "text", "label": "State", "pdf_field_name": "State", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 370.08, "t": 319.2, "r": 588.48, "b": 294 }, "text": "ZIP Code", "field_kind": "text", "label": "ZIP Code", "pdf_field_name": "ZIP Code", "pdf_field_type": "Text", "reading_order": 34 }, { "page": 1, "type": "TEXT", "location": { "l": 18.96, "t": 292.32, "r": 591.84, "b": 235.44 }, "text": "Per California State Law, Health and Safety Code, Section 103526 (c), permits only authorized persons as defined below to receive certified copies of Birth Records. Those who are not authorized by law to receive a certified copy will receive a certified informational copy marked “Informational, Not a Valid Document to Establish Identity.” Request for an informational copy do not require a sworn statement and do not require an item to be selected from the list below.", "reading_order": 35 }, { "page": 1, "type": "TEXT", "location": { "l": 19.2, "t": 226.8, "r": 171.84, "b": 214.8 }, "text": "To receive a Certified Copy, I am:", "reading_order": 36 }, { "page": 1, "type": "TEXT", "location": { "l": 18.96, "t": 213.36, "r": 589.2, "b": 188.16 }, "text": "○ The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)", "reading_order": 37 }, { "page": 1, "type": "TEXT", "location": { "l": 19.44, "t": 186.24, "r": 592.8, "b": 147.84 }, "text": "○ A party entitled to receive the record as a result of a court order or an attorney or a licensed adoption agency seeking the birth record in order to comply with the requirements of Section 3140 or 7603 of the Family Code. (Please include a copy of the court order.)", "reading_order": 38 }, { "page": 1, "type": "TEXT", "location": { "l": 19.2, "t": 146.16, "r": 567.36, "b": 107.28 }, "text": "○ A member of a law enforcement agency or a representative of another government agency, as provided by law, who is conducting official business. (Companies representing a government agency must provide authorization from the government agency.)", "reading_order": 39 }, { "page": 1, "type": "TEXT", "location": { "l": 19.2, "t": 105.84, "r": 467.04, "b": 93.12 }, "text": "○ A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant.", "reading_order": 40 }, { "page": 1, "type": "TEXT", "location": { "l": 19.44, "t": 91.92, "r": 555.12, "b": 66.96 }, "text": "An attorney representing the registrant or the registrant's estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant's estate.", "reading_order": 41 }, { "page": 1, "type": "TEXT", "location": { "l": 18.96, "t": 65.76, "r": 578.88, "b": 39.36 }, "text": "○ Appointed rights in a power of attorney, or an executor of the registrant's estate. (Please include a copy of the power of attorney, or supporting documentation identifying you as executor.)", "reading_order": 42 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TITLE", "location": { "l": 19.2, "t": 749.52, "r": 583.92, "b": 736.32 }, "text": "3. SWORN STATEMENT* (Must be signed in the presence of the Pasadena Vital Records Staff or a Notary Public.)", "reading_order": 0, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 20.88, "t": 711.84, "r": 589.2, "b": 684.96 }, "text": "I, ___, declare under penalty of perjury under the laws of the State of California, (Applicant's Printed Name)", "reading_order": 1 }, { "page": 2, "type": "FIGURE", "location": { "l": 30.84, "t": 726.36, "r": 255.6, "b": 701.76 }, "text": "", "field_kind": "text", "label": "I", "pdf_field_name": "I", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 21.6, "t": 671.76, "r": 589.44, "b": 650.16 }, "text": "that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a", "reading_order": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 21.12, "t": 645.12, "r": 344.16, "b": 632.16 }, "text": "certified copy of the birth certificate identified on this application form.", "reading_order": 4 }, { "page": 2, "type": "TEXT", "location": { "l": 17.04, "t": 604.32, "r": 585.12, "b": 544.8 }, "text": "Subscribed to this___ day of ___, 20___, at ___, (Day) (Month) (City) (State)", "reading_order": 5 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 103.2, "t": 623.04, "r": 158.04, "b": 594.36 }, "text": "Subscribed to this", "field_kind": "text", "label": "Subscribed to this", "pdf_field_name": "Subscribed to this", "pdf_field_type": "Text", "reading_order": 6 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 190.68, "t": 623.04, "r": 300.24, "b": 594.36 }, "text": "day of", "field_kind": "text", "label": "day of", "pdf_field_name": "day of", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 316.68, "t": 623.04, "r": 349.56, "b": 594.36 }, "text": "20", "field_kind": "text", "label": "20", "pdf_field_name": "20", "pdf_field_type": "Text", "reading_order": 8 }, { "page": 2, "type": "FIGURE", "location": { "l": 366.24, "t": 623.04, "r": 530.64, "b": 594.36 }, "text": "", "field_kind": "text", "label": "at", "pdf_field_name": "at", "pdf_field_type": "Text", "reading_order": 9 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 535.92, "t": 623.04, "r": 579.6, "b": 594.36 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined", "pdf_field_type": "Text", "reading_order": 10 }, { "page": 2, "type": "TEXT", "location": { "l": 304.32, "t": 603.6, "r": 318.24, "b": 593.76 }, "text": "20", "reading_order": 11 }, { "page": 2, "type": "TEXT", "location": { "l": 24.96, "t": 550.32, "r": 589.2, "b": 538.08 }, "text": "(Applicant's Signature)", "reading_order": 12 }, { "page": 2, "type": "TEXT", "location": { "l": 24.72, "t": 537.12, "r": 581.04, "b": 497.28 }, "text": "*If you are requesting a certified copy by mail, you must have the above statement and the certificate of acknowledgement notarized. Please note: The notary is not certifying the relationship, only that you are the person requesting the copy. Requests for an informational copy do not require your signature to be notarized.", "reading_order": 13 }, { "page": 2, "type": "TITLE", "location": { "l": 22.32, "t": 477.6, "r": 150, "b": 465.84 }, "text": "SUBMITTING APPLICATION", "reading_order": 14, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 33.6, "t": 446.16, "r": 75.36, "b": 434.4 }, "text": "By Mail:", "reading_order": 15 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 51.6, "t": 431.04, "r": 586.56, "b": 418.56 }, "text": "Payment may be made by check or money order made payable to the City of Pasadena Public Health Department.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 16 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 51.12, "t": 415.68, "r": 151.2, "b": 404.64 }, "text": "Do not mail cash.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 17 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 51.12, "t": 400.56, "r": 302.64, "b": 389.28 }, "text": "Please provide a self-addressed stamped envelope.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 18 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 51.12, "t": 385.44, "r": 385.68, "b": 372.96 }, "text": "The document(s) will be mailed to you within seven (7) business days.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 19 }, { "page": 2, "type": "TITLE", "location": { "l": 33.6, "t": 356.4, "r": 83.52, "b": 345.12 }, "text": "In Person:", "reading_order": 20, "level": 2 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 50.88, "t": 341.76, "r": 316.56, "b": 330 }, "text": "You will be asked to present valid photo identification.", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 21 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 50.4, "t": 326.88, "r": 547.92, "b": 300 }, "text": "Payment may be made with a credit card (American Express, Discover, MasterCard, Visa, Debit) cash or by check/money order made payable to the City of Pasadena Public Health Department.", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 22 }, { "page": 2, "type": "TEXT", "location": { "l": 33.6, "t": 283.2, "r": 391.44, "b": 270.96 }, "text": "Please send or bring your completed application with the appropriate fee(s) to:", "reading_order": 23 }, { "page": 2, "type": "TEXT", "location": { "l": 33.6, "t": 260.88, "r": 235.2, "b": 248.4 }, "text": "City of Pasadena Public Health Department", "reading_order": 24 }, { "page": 2, "type": "TEXT", "location": { "l": 33.84, "t": 246.48, "r": 126, "b": 234.48 }, "text": "Vital Records Office", "reading_order": 25 }, { "page": 2, "type": "TEXT", "location": { "l": 34.08, "t": 232.08, "r": 225.6, "b": 219.84 }, "text": "1845 North Fair Oaks Avenue, Room 1610", "reading_order": 26 }, { "page": 2, "type": "TEXT", "location": { "l": 34.08, "t": 216.96, "r": 129.36, "b": 205.2 }, "text": "Pasadena, CA 91103", "reading_order": 27 }, { "page": 2, "type": "TEXT", "location": { "l": 33.84, "t": 191.04, "r": 357.84, "b": 163.2 }, "text": "http://ww5.cityofpasadena.net/public-health/birth-and-death-records/\n(626) 744-6010", "links": [ { "uri": "http://ww5.cityofpasadena.net/public-health/birth-and-death-records/", "dest": null, "action_type": "/URI", "bbox": [ 33.75, 177.4, 358.18, 195.89 ] } ], "reading_order": 28 }, { "page": 2, "type": "TEXT", "location": { "l": 37.44, "t": 105.36, "r": 123.84, "b": 93.12 }, "text": "OFFICE USE ONLY:", "reading_order": 29 }, { "page": 2, "type": "TEXT", "location": { "l": 33.84, "t": 75.84, "r": 588, "b": 62.16 }, "text": "ID/DL#: ___ Exp: ___ LRN#: ___ BN#: ___ City Official: ___", "reading_order": 30 }, { "page": 2, "type": "FIGURE", "location": { "l": 155.04, "t": 54.96, "r": 168.24, "b": 41.28 }, "text": "", "reading_order": 31 }, { "page": 2, "type": "TEXT", "location": { "l": 32.64, "t": 54.72, "r": 561.6, "b": 30 }, "text": "Express/Same day service (additional fee required)\nRevised 6/2017", "reading_order": 32 }, { "page": 2, "type": "TEXT", "location": { "l": 34.56, "t": 54.72, "r": 244.32, "b": 41.04 }, "text": "○ Mail out", "reading_order": 33 }, { "page": 2, "type": "TEXT", "location": { "l": 168.72, "t": 54.72, "r": 244.08, "b": 42.24 }, "text": "Hold for Pick-Up", "reading_order": 34 }, { "page": 2, "type": "FIGURE", "location": { "l": 318.96, "t": 54.72, "r": 331.44, "b": 41.04 }, "text": "", "reading_order": 35 } ] } ]