Step 1 of 5

Names & Identity

Begin the sacred record of origin, establishing names and identity.

Your Email Address * Your record will be delivered to this address. A valid email address is required.

First Name * First name is required.

Last Name * Last name is required.

Middle Name

Informal Names / Nicknames

Name Origin

Name Etymology / Meaning

Step 2 of 5

Chronicle of Birth

Document the precise moment and location of this life's beginning.

Date of Birth * Date of birth is required.

Time of Birth

Birth Facility * Name of hospital, birth center, or facility. Birth place is required.

Birth Location * City and state at minimum. Birth location is required.

Birth Order

APGAR (1 min) Medical assessment at 1 min.

APGAR (5 min) Medical assessment at 5 min.

Sacred Connection — Time Connected to Placenta

Days

Hours

Minutes

Seconds

Step 3 of 5

Provenance

Record the lineage and bonds that form the foundation of this identity.

Parents

Father's Full Name

Father's Date of Birth

Father's Time of Birth

Time unknown

Mother's Full Name

Mother's Date of Birth

Mother's Time of Birth

Time unknown

Grandparents

Maternal Grandfather

Maternal Grandmother

Paternal Grandfather

Paternal Grandmother

Love Story & Conception

Where Parents First Met

When Parents Married

Parents were not married

When Conceived

Primary Caregivers

Primary Caretaker

Secondary Caretaker

Print Preference

Baby's Prints

Step 4 of 5

Physical Attributes

Detail the physical form and essence of the newborn.

Gender

Race / Ethnicity

Height (ft)

Height (in)

Weight (lbs)

Weight (oz)

Head Circumference

Birth Temperature

Birth Type

Eye Color

Hair Color

Blood Type

Nationality

Step 5 of 5

Final Inscription

Review the complete record and seal the permanent inscription.

By submitting this provenance record, I confirm that the information provided is accurate to the best of my knowledge. I understand that this record will be used to produce a permanent archival Birth Codex™ document and cannot be reproduced or replaced once issued.

I confirm the accuracy of this record. *

Provenance Received.

Your record has been submitted. A watermarked proof will be generated and sent to your email within a few minutes.

Return to My Birth Codex™

Each Birth Codex™ contains over 100 unique data points derived from your birth information.

Questions Left (All Steps)

This step: 7/7 —

Includes all steps. Draft autosaves locally (if enabled).

What Happens Next

The sequence

Your data is encrypted and stored securely

150+ identity dimensions are calculated from your record

A watermarked proof PDF is generated for your review

Upon payment, the archival Codex enters print production

Printed on 100lb cotton-rag paper, shipped to your address