This government document is issued by Department of Health for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:-o2sxg2obgu&q=https://www.health.pa.gov/topics/Documents/Reporting-Registries/SRN%25202019-11%2520Local%2520Registrar%2520Requisition%2520for%2520Vital%2520Records%2520Forms%2520and%2520Supplies.pdf&sa=U&ved=2ahUKEwiqkpGzr9D8AhWFQEEAHQ4BD8c4ChAWegQICBAC&usg=AOvVaw0XM7Tp2Hm06KnPrpS7_v2t