Request Certified Vital Record Form

Request for a Certified Vital Record

Your Name: ____________________ Signature: ______________________________
PLEASE HAVE YOUR PHOTO ID READY

Address: ______________________________ Telephone #: _____________________
City: ________________________________ State _______ Zip Code: __________
Relationship to person name in request: _______________________________________

For a Birth Certificate: Number of Copies:_____
Full name of child at birth: _________________________________________________
Date of Birth: ____________________________________________________________
Mother's Maiden Name: ___________________________________________________
Father's Name: __________________________________________________________
New name if child's name was changed: ______________________________________

For a Marriage Record: Number of Copies:___
Name of Husband: _______________________________________________________
Maiden name of wife: _____________________________________________________
Place of Marriage: ________________________________________________________
Date of Marriage: ________________________________________________________

For a Death Certificate: Number of Copies:___
Name of Deceased: _______________________________________________________
Date of Death: _____________________________________Age at Death___________
Father's name: _________________________ Mother's name: ____________________
Residence at time of death: _________________________________________________
Do you require cause of death on the certificate? Yes _______ No _______

For a Domestic Partnership Record: Number of Copies:___
Name of Domestic Partner 1:________________________________________________
Name of Domestic Partner 2: _______________________________________________
Place Domestic Partnership Affidavit Filed: ___________________________________
Date of Domestic Partnership:_______________________________________________

Cost is $4 by mail [please include a self addressed envelope],
or $4 in person. Additional copies of the same record are $2 each.

Mail requests may be sent to the above address.

Valid photo id with signature and current address or two other forms of id must be presented. If mailing send a photo copy of your ID.