Baptismal Certificate Request

Baptismal Certificate Request
Full Name at the time of Baptism *
(office use only: Rec'd _____________ Mailed _____________)
Date of Birth*

MonthDayYear
Date
City of Birth*
Father's Full Name*
Mother's Full Name with Maiden Name*
Approximate Date of Baptism*

Name of person requesting certificate*
Street Address*
City, State AND Zip Code*
Your Email*
example@example.com
Phone Number*

Area CodePhone Number
In order to protect the privacy of the individuals involved, certificates are only issued to the parent of a minor child, or the person to whom the certificate is referring. NO certificates are issued for genealogical purposes.

I have read the above information, and certify that this is my own or my child's certificate that I am requesting.
Your signature:*

Clear

Would you like a copy submitted to St. Anastasia's Religious Education Office?*

YESNO
If the certificate is to be sent to a Parish other than St. Anastasia, please type in the Name of the Parish:
To the Attention of:
Address of the Parish where you would like this certificate mailed:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: