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Application for Certified Copy of Birth Record H105.102 REV 05/2015 BIRTH Pennsylvania Department of Health ? Division of Vital Records PART 1: By my signature below, I state I am the person whom
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102 rev 052015 refers to the revised version of form 102 which was last updated in May 2015.
Entities or individuals who meet the specified criteria by the regulatory authority.
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The purpose of form 102 rev 052015 is to collect specific information required by the regulatory authority.
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