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DATE OF EVENT MM/DD/CCYY 1C. LAST 4. CITY OF EVENT 6. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD 5. COUNTY OF EVENT STATEMENT OF CORRECTIONS TO BIRTH DEATH OR FETAL DEATH RECORD 8. ITEM NUMBER TO BE CORRECTED 9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL RECORD 10. CORRECTED INFORMATION AS IT SHOULD APPEAR LIST ONE ITEM PER LINE REASON FOR CORRECTION We the undersigned hereby certify under penalty of perjury that we have personal knowledge of the above facts and that the information g ...

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