Authorization To Release A Vital Record printable pdf download

Authorization To Release A Vital Record

Authorization to Release a Vital Record

Date: _______________________

I, _________________________, hereby authorize ________________________

(

name of person eligible for record)

name of person to obtain record)

to obtain the following record: (check all that apply)

birth – date of event _______________

death - date of event ______________

marriage – date of event ____________

of ______________________________.

(

name of person on record to be released)

_________________________________________

Signature of Person Eligible for Record

______________________________

Relationship to Person on Record

Personally appeared before me this _________ day of ___________________, 20 __,

at _________________, Maine, by __________________________ to be his/her free

)

(name of person acknowledged

act and deed.

_________________________

Signature of Notary/Attorney

__________________________

Printed Name of Notary/Attorney

__________________________

Date Commission Expires

7-13-2010

Authorization To Release A Vital Record