Van Buren County Clerk Vital Record Request

SUZIE ROEHM VAN BUREN COUNTY CLERK

212 Paw Paw Street, Suite 101, Paw Paw, MI 49079-1496 Phone (269) 657-8218, Option 6; Fax (269) 657-8298 Email: Clerk@vanburencountymi.gov
REQUEST FOR COPY/COPIES OF VITAL RECORDS

BIRTH RECORDS
Photo Identification must be presented when requesting a birth record in person; a photocopy is required for mail/online requests. THE ADDRESS ON ID MUST MATCH THE MAILING ADDRESS^*.

*IF the address on your ID does NOT match the address mailing address you provided. Please upload additional proof such as a recent piece of non-junk mail showing your name and current mailing address.
Please attach photo identification: FRONT of ID.*

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Please attach photo identification: BACK of ID.*

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The address on my ID matches the mailing address given.*

YesNo
Please upload additional proof here such as a recent piece of non-junk mail showing your name and current mailing address.*

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NAME ON BIRTH RECORD*
DATE OF BIRTH*

MonthDayYear
Date
PLACE OF BIRTH*
If home birth, please provide the city and state.
MOTHER'S FULL MAIDEN NAME*
FATHER'S FULL NAME*
If not listed, please write "N/A."
Check one of the following:*

I am requesting my own birth record.I am requesting my child's birth record.I am an heir of the person named in the record.I am a legal representative of the person named in the record.
Please provide documentation showing how you are an heir, or legal representative. *

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Submission
I SIGN THIS DOCUMENT STATING THAT I AM NOT USING THIS CERTIFICATE FOR FRAUDULENT OR DECEPTIVE PURPOSES, SECTION 2894, ACT 368, PUBLIC ACTS 1978 AS AMENDED; MCL 333.2894.
Signature*

Clear
To sign: If you're on a computer, use your mouse. Click, hold, and draw your signature. If you're on a touchscreen device, use your finger to draw your signature.
DATE*

MonthDayYear
Date
Fees:$15.00 for one certified copy of a birth, death or marriage record.

$5.00 for each additional copy of the same record purchased at the same time.

Your total is ${iAm65}.

After clicking "submit" you will receive a confirmation email with further instructions on how to submit payment.

SUZIE ROEHM VAN BUREN COUNTY CLERK