Beruflich Dokumente
Kultur Dokumente
Birth
Stillbirth
Death
SS
County of ____________________________:
FIRST; the information below lists the particulars of the record in question
Name currently on record ___________________________________________________________________
Place of birth or death ____________________________________ Date of birth or death ______________
(facility, city and county)
SECOND; the following information is incorrect or missing and should be corrected as follows
Item to be corrected
Incorrect information
Correct information
______________________
_____________________________ _________________________________
______________________
_____________________________ _________________________________
______________________
_____________________________ _________________________________
______________________
_____________________________ _________________________________
______________________
_____________________________ _________________________________
(If additional room is needed, complete another affidavit.)
PLEASE NOTE: Most corrections, changes or additions to records require additional supporting
documentation. Submitting this form does not guarantee completion of your request.
VR 400