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PLC:

a004le

Agency:

dickinson county clerk and register of deeds

For:

birth certificates

Phone:

906-774-0988

Address:

705 south stephenson avenue
iron mountain, michigan 49801

*Required Field

Payment Information

This is the name of the person at birth.

*Birth Name:

Middle:

*Last:

*Date of Birth:

(Month / Day / Year)

Email Address:

Notes:

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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