______________________________________________________________________________
CERTIFICATE OF ADOPTION
IN THE ________ COURT
OF THE STATE OF OREGON
FOR THE COUNTY OF
___________
In the Matter of the Adoption of:
___________________________
File No.___________
Name after Adoption
This is to certify that on the ___ day of ________, 2___, a Judgment of Adoption was granted by the Honorable Judge ____________ granting the adoption of the above-named person by _________________.
The adopted person, above named, was born in the City of ___________, County of ________, State of ________, on the __ day of _____, 2__.
Dated at ________, Oregon, this __ day of ___, 2__.
(Title of the Clerk of the Court)
(SEAL) By _______________
Deputy
______________________________________________________________________________
ORS 109.410