Certified Copy of Vital Record Request Form

Certified Copy of Vital Record Request Form
APPLICATION FOR A NON-GENEALOGICAL
CERTIFICATION OR CERTIFIED COPY OF VITAL RECORD
Certified CopyCertified Copy for an Apostille SealCertification
Requestor's Relationship to Person on Record
(proof is required for certified copy)

Cancelof
Requestor's Signature
Date (of request)

MonthDayYear
Date
Name of Requestor

First NameMiddle NameLast Name
PassportDriver's LicenseSchool / SportsVeterans' BenefitsSocial Security Card / BenefitsMedicareWelfare / DisabilityOther
Email Address
example@example.com
Daytime Phone Number
Birth
Child's Name at Birth

First NameMiddle NameLast Name
No. Requested Copies
Place of Birth

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Name of Child's Parents (name given at birth or on birth certificate / Maiden Name)
Parent A

First NameMiddle NameLast Name
Parent B

First NameMiddle NameLast Name
If Child's name was changed:
New Name
Describe Change
MARRIAGECIVIL UNIONDOMESTIC PARTNERSHIP
No. Requested Copies
Place of Birth

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Event

MonthDayYear
Date
Name of Spouses (name given at birth or on birth certificate / Maiden Name)
Spouse A

First NameMiddle NameLast Name
Spouse B

First NameMiddle NameLast Name
DEATH
Name of Decedent

First NameMiddle NameLast Name
No. Requested Copies
Place of Death

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Death

MonthDayYear
Date
Name of Decedent's Parents (name given at birth or on birth certificate/Maiden Name)
Parent A

First NameMiddle NameLast Name
Parent B

First NameMiddle NameLast Name
Completed ApplicationProof of RelationshipPaymentAcceptable Forms of IDMailing Address Matches ID
FOR STATE USE ONLY
CashM/OCheckWaived
Amount
ID Viewed Processed By
Should be Empty:

Certified Copy of Vital Record Request Form

Birth

DEATH

FOR STATE USE ONLY