Form Reg-27a - Application For A Non-Genealogical Certification Or Certified Copy Of A Vital Record

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New Jersey Department of Health
APPLICATION FOR A NON-GENEALOGICAL CERTIFICATION
Vital Statistics and Registry
OR CERTIFIED COPY OF A VITAL RECORD
P.O. Box 370 - Trenton, NJ 08625-0370
Click here to complete an application online,
or visit:
Requestor’s Relationship to
Requestor’s Signature
Certified Copy
Person on Record
Certified Copy for an Apostille Seal
(proof is required for certified copy)
Certification
Date
(of request)
/
/
Name of Requestor
Reasons for Request
Passport
First
Middle
Driver’s License
Last
School / Sports
Veterans’ Benefits
Current Mailing Address
(must match address on ID)
Social Security Card / Benefits
Street
Medicare
Welfare / Disability
City
State
Zip Code
Other:
Email Address
Daytime Phone Number
(
)
-
@
.
BIRTH
Child’s Name at Birth
First
Middle
Last
No. Requested Copies
Place of Birth
County
Date of Birth
/
/
City
State
Name of Child’s Parents
(name given at birth or on birth certificate / Maiden Name)
Parent A
First
Middle
Last
Parent B
First
Middle
Last
If Child’s name was changed:
New Name
Describe Change:
MARRIAGE
CIVIL UNION
DOMESTIC PARTNERSHIP
No. Requested Copies Place of Event
County
Date of Event
/
/
City
State
Name of Spouses
(name given at birth or on birth certificate / Maiden Name)
Spouse A
First
Middle
Last
Spouse B
First
Middle
Last
DEATH
Name of Decedent
First
Middle
Last
No. Requested Copies
Place of Death
County
Date of Death
/
/
City
State
Name of Decedent’s Parents
(name given at birth or on birth certificate / Maiden Name)
Parent A
First
Middle
Last
Parent B
First
Middle
Last
Completed Application
Proof of Relationship
Have you enclosed and completed all
required information?
Payment
Acceptable Forms of ID
Mailing Address Matches ID
FOR STATE USE ONLY
REG-27a
Amount:
$
Processed By:
Payment Type:
Cash
M/O
Check
Waived
ID Viewed
SEP 17

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