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State of California — Health and Human Services Agency SWORN STATEMENT 202207391 California Department of Public Health 1, Jose ivc, yve. R , V C& .s , declare under penalty of perjury under the laws of the (Applicant's Printed Name) State of California, that 1 am an authorized person, as defined in California Health and Safety Code Section 10352.6 (c), and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following individual(s): Registrant (Name of person whose certificate you are requesting) Applicant% Relationship to Registrant (Must be an authorized person) krene ?OkY; r,tcK Qv“nlana R vas 5 Po\)Se. f R (The remaining information must be completed in the presence of a Notary Public or CDPH Vitaecords Subscribed to this 30 day of J u , 20 2 at G re-( /- Al (Day) (Month) (City) (State) (Applicant's Signature) CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of N -c- (lj raf County of LL 1 Pi4,401 On 6,'3C) as before me, Za�ti0`( 5,t t7 "r` i personally appeared. Jose- 11:5uA1 PiVas (Insert name and title of the officer) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) Is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the persons) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal. GENERAL NOTARY - State of Nebraska f sf=A1 ZACHARY BUTZ My Comm. Exp. May 16, 2025