APPLICATION FOR A CERTIFIED COPY OF A BIRTH CERTIFICATE
Office of the City Clerk/ One City Hall Plaza/ Manchester, NH 03101/ 603-624-6455
Name of Registrant:
(First Name) (Middle Name) (Last Name)
Date of Birth: _____/_____/_____ Place of Birth (City/Town):
Father’s Name:
(First) (Last)
Mother’s Maiden Name:
(First) (Last)
Purpose for which certificate is requested:
Your Signature: Your relationship to registrant:
Please Print All Information
Please mail completed application to address above and include a stamped envelope for return service.
NH State Law for the search of the file requires a fee of fifteen dollars for any one record. The State also
requires a valid picture identification of the individual applying for the birth certificate before a record
will be released. If we find that record and you meet New Hampshire’s access requirements, you will be
issued a certified copy of that certificate. THE FEE IS NON-REFUNDABLE IN THE EVENT THE
RECORD IS NOT LOCATED.
Number of Copies: ($15 first copy, $10 each additional)
The certificate(s) will be mailed to the following address: (please print)
Name of applicant:
(First) (Middle) (Last)
Address of applicant:
(Street) (City/Town) (State) (Zip Code)
Applicant Phone #: ( ) - Email Address (optional)
NOTICE
Any person shall be guilty of a CLASS B felony if he/she willfully and knowingly makes any false
statement in an application for a certified copy of a vital record. (RSA 126:24)
OFFICIAL USE ONLY:
Number
Requested
Issued
