Vital Record Correction - Amendment Form
State File Number
AMENDMENT TO NJ VITAL RECORD OF:
BIRTH
DEATH
FETAL DEATH
MARRIAGE
REMARRIAGE
CIVIL UNION
REAFFIRMATION OF CIVIL UNION
DOMESTIC PARTNERSHIP
SECTION 1
INFORMATION AS IT APPEARS ON THE CURRENT RECORD:
Name (or Names, in the case of Marriage, Remarriage, Civil Union, Reaffirmation of Civil Union or Domestic Partnership)
Date of Event
-
Month
-
Day
Year
Date
County of Event
-
Month
-
Day
Year
Date
City/Municipality of Event
SECTION 2
Rows
Field to be Amended
Item as Currently Recorded on Record
Item as it Should Appear
1
2
3
4
5
SECTION 3
3A. Signature
Printed Name
Date
-
Month
-
Day
Year
Date
Address
Relationship to Individual on Vital Record
3B. Signature
Printed Name
Date
-
Month
-
Day
Year
Date
Address
Relationship to Individual on Vital Record
3C. AFFIDAVIT SECTION
Documentation presented to establish the validity of the amended information reported in Section 2:
FOR OFFICIAL USE ONLY
DO NOT WRITE BELOW THIS LINE
Secondary Item(s) Approval Date:
-
Month
-
Day
Year
Date
Parents Given Option to Change Child's Last Name?
Yes
No
N/A
Submit
Should be Empty: