Santa Clara — VS-108

Source: https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/VS108.pdf

ORDER ESTABLISHING FACT OF BIRTH

In the Superior Court of the State of California

In and for the County of __________________

In the matter of the petition of

________________________________ Number __________________________

To establish the fact of birth of Department ________________________

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The verified petition of _______________________________________________________ t o establish the fact of the birth of

____________________________________________________________________________________ having been filed herein on

the ____________ day of _________________, A.D., 20, and such petition having by an order of court been duly

set for hearing on the __________ day of ______________, A.D., 20, at the hour of ________ o’clock ____ m. of

said day; and now on said day said matter coming on regularly for hearing and it appearing to the satisfaction of this court from the

evidence introduced that the said _______________________________________________________________, petitioner herein, is

beneficially interested in establishing of record the fact of the birth of said _________________________________________, in that

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__________________________________________________________________________________________________________;

and it appearing that on the __________ day of ___________, A.D., 20, a _______________________ child was

born to _____________________________________________________________________________________________, parent

and________________________________________________________________________________________________, parent;

that the name of said child is __________________________, __________________________, _____________________________; (First) (Middle) (Last)

that said birth has not been registered in conformity with the provisions of law in effect at the time of said birth or such record has been

lost or destroyed after having been filed; and no one appearing at said hearing to oppose the making of this order;

It is therefore ordered, adjudged, and decreed that on the ___________ day of ____________, A.D., 20, a

___________________ child of the name of ______________________________________________________________________

was born to__________________________________________________________________________________________, parent,

and________________________________________________________________________________________________, parent,

at _____________________________, County of __________________________________, State of _________________________.

Done in court this ___________ day of ______________, A.D., 20.

►__________________________________________________ Judge of the Superior Court

Before filing the above order, insert in the certificate form below, as of the date of the birth, the personal and statistical particulars required for the records of the State Registrar. A certified copy of the above order must be filed with the State Registrar before the order shall become effective. USE BLACK INK ONLY.

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS FORM VS 108 (Rev. 04/20)

COURT ORDER DELAYED REGISTRATION OF BIRTH STATE OF CALIFORNIA

NO ERASURES, WHITEOUTS, PHOTOCOPIES,

______________________________________ OR ALTERATIONS _______________________________________ STATE FILE NUMBER LOCAL REGISTRATION NUMBER

TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS FORM BECOMES THE OFFICIAL BIRTH RECORD

1A. NAME—FIRST 1B. MIDDLE 1C. LAST

FACTS 2. SEX 3A. THIS BIRTH, SINGLE, TWIN, ETC. 3B. IF MULTIPLE, THIS CHILD BORN 1ST, 2ND, ETC. 4. DATE OF BIRTH—MM/DD/CCYY
OF
BIRTH

5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY 5B. CITY OR TOWN 5C. COUNTY OR COUNTRY

6A. NAME OF PARENT—FIRST 6B. MIDDLE 6C. LAST (BIRTH) 6D.RELATIONSHIP
MOTHER
FATHER
PARENT

PARENT 7. STATE/FOREIGN COUNTRY OF BIRTH 8. DATE OF BIRTH—MM/DD/CCYY

9A. NAME OF PARENT—FIRST 9B. MIDDLE 9C. LAST (BIRTH) 9D.RELATIONSHIP
MOTHER
FATHER
PARENT

PARENT 10. STATE/FOREIGN COUNTRY OF BIRTH 11. DATE OF BIRTH—MM/DD/CCYY

12. NAME AND KIND OF DOCUMENT, BY WHOM ISSUED AND SIGNED, DATE ISSUED, DATE ORIGINAL MADE

A

ABSTRACT OF SUPPORTING B DOCUMENTS

C

D

E

F

13. DATE OF BIRTH OR AGE, BIRTHPLACE, AND BIRTH NAMES OF PARENTS

A

REGISTRANT INFORMATION AS STATED IN B DOCUMENTS

C

D

E

F

14. Offered for filing pursuant to order number ____________________________________ of the Superior Court of the State/Country of _____________ in and

    for the County of _______________________________________________________ made the _______________ __ day of ___ _______________________,

STATE A.D., 20 _____ _ establishing of record the fact of birth in the State or Country of ________________________________________. REGISTRAR USE ONLY 15A. DATE OF DEATH—MM/DD/CCYY 15B. STATE FILE NO.

16. CDPH - VITAL RECORDS 17. DATE ACCEPTED FOR REGISTRATION

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS FORM VS 108 (Rev. 04/20)