Form Vs-39b - Request For Copy Of Birth Certificate
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1REQUEST FOR COPY OF BIRTH CERTIFICATE
VS-39B
Revised: 8/17/00
PLEASE PRINT
DO NOT MAIL CASH
FULL NAME AT BIRTH:_________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
DATE OF BIRTH: ______/______/_____
PLACE OF BIRTH: ______________________________________________________
MONTH DAY
YEAR
TOWN/CITY
FATHER’S FULL NAME: ________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________________
FIRST
MIDDLE
MAIDEN NAME
PERSON MAKING THIS REQUEST:
NAME: ______________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: ___________________________________________________________________________________________________________
NUMBER
STREET
TOWN/CITY: _____________________________________
STATE: ________________ZIP CODE: _____________________
X
_____________________________________________________________________________________________
SIGNATURE:
RELATION TO PERSON NAMED IN CERTIFICATE: ________________________________________________________________________
______________________________________________________________________________
REASON FOR MAKING REQUEST:
CERTIFICATE SIZE:
WALLET SIZE
NOTE THAT THE WALLET SIZE BIRTH CERTIFICATE CONTAINS LESS
INFORMATION THAN THE FULL SIZE CERTIFICATE. IT MAY NOT SATISFY ALL
PROOF OF IDENTIFICATION REQUIREMENTS SUCH AS THOSE NEEDED TO
OBTAIN PASSPORTS.
NUMBER OF COPIES
FULL SIZE
REQUESTER MUST ATTACH A COPY OF PICTURE IDENTIFICATION
FEE: $5.00 PER COPY. MONEY ORDER MADE PAYABLE TO THE TOWN/CITY OF BIRTH
MAIL THIS REQUEST WITH PAYMENT TO THE TOWN CLERK AT THE TOWN/CITY OF BIRTH
FOR TOWN CLERK ADDRESSES PLEASE SEE ALPHABETICAL LISTING BY TOWN
ATTACH A COPY OF PICTURE IDENTIFICATION HERE:
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Parent category: Business