Washtenaw County - Request For Certified Copies Form 2005

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M.C.L.A. 333.2881 ex seq.
LAWRENCE KESTENBAUM
County Clerk/Register of Deeds - Vital Records
M.D.P.H. Vital Statistics Manual
200 North Main Street, Suite 100
P. O. Box 8645
Ann Arbor, MI 48107-8645
Telephone Number: 734-222-6720
WASHTENAW COUNTY – REQUEST FOR CERTIFIED COPIES
All copies issued by this office are certified copies for events which occurred in Washtenaw County Only
FIRST COPY OF EACH BIRTH, DEATH, OR MARRIAGE RECORD: $15.00;
ADDITIONAL OF SAME RECORD AT SAME TIME: $5.00
NOTE: BIRTH CERTIFICATES FOR 65 & OVER – FIRST COPY IS $5.00
CHECK TYPE OF RECORD REQUESTED, FILL OUT APPROPRIATE SECTION AND SIGN AT BOTTOM
SECTION A
BIRTH CERTIFICATE
SECTION B
MARRIAGE LICENSE (COPIES ONLY)
SECTION C
DEATH CERTIFICATE -- BUSINESS NAME (cc- $2.00) -- MILITARY DISCHARGE (no fee)
SECTION A – Birth
Number of Copies ___________
Birth records for newborn children are not immediately available.
All unwed births prior to October 1978 may be obtained only from Lansing)
(
Most Birth Certificates filed in Washtenaw County after July 1974 were filed with parent social security number shown on the record
FULL NAME ON BIRTH RECORD:____________________________________________________________________
DATE OF BIRTH:________________________________________HOSPITAL / CITY OF BIRTH:________________
MOTHER’S FULL MAIDEN NAME:___________________________________________________________________
FATHER’S FULL NAME:_____________________________________________________________________________
SECTION B – Marriage
Number of copies ______________
GROOM’S NAME AT TIME OF APPLICATION:________________________________________________________
BRIDE’S NAME AT TIME OF APPLICATION:__________________________________________________________
BRIDE’S MAIDEN NAME:____________________________ DATE OF MARRIAGE:__________________________
SECTION C – Death, Military Discharge, Business Name
Number of copies __________
NAME ON RECORD:_________________________________________________________________________________
DATE: ______________________________________________________________________________________________
(date of Death,
date of Business filing
or
date of Military Discharge)
A copy of requester’s valid driver’s license or state issued ID & a self addressed stamped envelope must accompany mail requests
Requester’s Name ________________________________________________________________
Address ______________________________________City / State ________________________
Phone # (______)______________________________________
Zip Code ___________
****REQUESTER’S SIGNATURE:_____________________________________________________________________
DL / STATE ID#:____________________________________________________State___________Expires__________
CLERK________________________
PAYMENT
CA
CK
CC
RECORD NUMBER_________________
Rev 05/05

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