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Vital Statistics Request Form

  1. What is the name of the person whose information you are requesting?

  2. For Birth Certificates
  3. If requesting a birth certificate, please enter the date of birth.

  4. Last, First, Middle

  5. Last, First, Middle

  6. For Death Certificates
  7. If requesting a death certificate, please enter the date of death.

  8. Include SSN

    If requesting a death certificate for a death that occurred within the last 5 years, do you need the SSN included on the certificate?

  9. Authorized SSN Recipients

    To have the SSN included on a death certificate, please select one of the following and attach documentation.

  10. Cost

    Certificates are $25 each.  

  11. Please include a phone number where you can be reached if there is a question or problem with your request.

  12. Please include your email address so we can contact you in the event there is a question about your request.

  13. Leave This Blank:

  14. This field is not part of the form submission.