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Birth certificate PDF
Birth certificate
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When was this letter written?
Date Mailed:
DD slash MM slash YYYY
Who is making this request, and what is their name and address?
Full Name:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
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Which office will be handling your request, and what is its name and address?
Name of Office:
Name of Contact Person:
Title of Contact Person:
Salutation of Letter (examples: Dear Mr. Smith, To Whom It May Concern, Dear Sir or Madam):
Office Address:
Office City:
Office State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Office Zip Code:
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What number of copies of the birth certificate do you need?
Number of Copies (written):
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Number of Copies (numerical):
1
2
3
4
5
6
7
8
9
Are you looking for your own birth record?
Requesting Your Own Birth Certificate?:
Yes
No
Your Name as it Appears on Certificate:
Your Gender:
Male
Female
What is the name of the individual whose birth certificate you are requesting?
Full Name of Person as it Appears on Certificate:
Person's Gender:
Male
Female
Your Relationship to Person (mother, father, etc.):
The person whose name is on the certificate was born when and where?
Date of Birth:
DD slash MM slash YYYY
Place of Birth (name of hospital or street address of place of birth):
Birth City:
Birth County:
Birth State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Who are the parents of the individual whose name is on the certificate?
Full Name of Father (first, middle, last, suffix):
Full Name of Mother (first, middle, last, suffix):
Maiden Name of Mother:
Why is this request being made?
This certificate is being requested for the purpose of:
How will you pay for the certificate(s) that have been requested?
Type of Payment:
Certified Check
Personal Check
Money Order
Amount of Payment ($):
How would you like to be contacted by the Office of Vital Statistics?
Email Address:
Telephone Number (###-###-####):
Fax Number (###-###-####):
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