Free 05438.pdf - Indiana

RECORD OF ADOPTION
State Form 5438 (R6/9-07)

INDIANA STATE DEPARTMENT OF HEALTH VITAL RECORDS B4 99 2 N. Meridian St. Indianapolis Indiana 46204
STATE OFFICE USE REGIS NO. _________________________________

Send one copy with original copy of the Comprehensive Medical History Report (I.C. 31-19-2-7) (Information confidential in accordance with IC 16-37-1-10)

ORIG. REGIS NO. ___________________________ LOCAL NO. _______________________________ FILE DATE

PART I. This information will be used to prepare the new certificate of birth.

________________________________ (Middle) (Last) 2. Date of Birth (month,day,year)

FATHER ADOPTIVE NATURAL (Specify) MOTHER ADOPTIVE NATURAL (Specify)

1. NAME OF FATHER

(First)

3. Birthplace (State or foreign country) 7. PRESENT LEGAL NAME OF MOTHER (First)

4. Race (Middle)

5. Usual Occupation (Last)

6. Kind of Business or Industry 8. Maiden Surname

9. Date of Birth

10. Birthplace (State or foreign country)

11. Race

12. Present Mailing Address of Adoptive Parents (number and street, city, state, and zip code)

13. Name of Attorney or Agency handling Case

Mailing Address (number and street, city, state, and zip code)

PART II. This information must be given as of date of birth. It is needed to locate and seal the original certificate of birth.

CHILD'S PERSONAL DATA

14. Name of Child at Birth (First) 15. Sex 16. Date of Birth (month, day, year)

(Middle)

(Last)

17. Place of Birth (City or Town, County, and State/Country)

18. Name of Father (First) NATURAL PARENTS' DATA 19. Maiden Name of Mother (First)

(Middle)

(Last)

(Middle)

(Last)

PART III. The clerk of court shall complete Parts I and II before the final decree of adoption is entered; then complete Part III and forward this record to the Indiana State Department of Health.

CERTIFICATION OF CLERK OF COURT

20. I hereby certify that the child described above was adopted by the parents(s) on ___________________ Date ____________________ Month _________________ Year ______________________________________________________ Cause Number

and shall now bear the name _________________________________________________________________________________________________________ S-E-A-L _________________________________________________________________ 21. Signature of Court Clerk ___________________________________________ 22. Date signed (month, day, year)

____________________________________________________________ 23. Court Clerk in and for the county of
PART IV. When birth occurred in the State other than Indiana, the State Registrar forward this record to the proper State Registration Agency.

____________________________________ State of

CERTIFICATION 24. I hereby certify that this record was received on the________________________________________ day of _________________________ 20__________________ OF STATE REGISTRAR Signature ___________________________________________________________________________________