Fillable Application for Certified Copy of Vermont Birth or (City of Burlington)

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Application for Certified Copy of Vermont Birth or (City of Burlington)

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The Application for Certified Copy of Vermont Birth or (City of Burlington) form is 2 pages long and contains:

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  • 19 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for City of Burlington

BROWSE CITY OF BURLINGTON (VT) FORMS

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Application for Certified Copy of Vermont Birth or Death Certificate
* = Required Field July 1, 2019
Use this form to request a certified birth certificate or death certificate for one person.
Multiple copies of the same certificate can be requested with this form.
Birth Certificate (BC)
Name of Child: First______________________ Middle _____________ Last*__________________ Suffix __
Date of Birth*: __ __/__ __/__ __ __ __ Sex*: ☐ Male ☐ Female Town of Birth*:_________________
Name of Mother/Parent: First______________ Middle _____________ Last __________________________
Name of Father/Parent: First_______________ Middle _____________ Last __________________________
Is this a Certificate of Live Birth for a Foreign-Born Child? ☐ Yes ☐ No
Death Certificate (DC)
Name of Deceased: First ___________________ Middle ____________ Last*_________________ Suffix __
Date of Death*: __ __/__ __/__ __ __ __ Sex*: ☐ Male ☐ Female Town of Death*: ________________
Name of Mother/Parent: First______________ Middle _____________ Last __________________________
Name of Father/Parent: First_______________ Middle _____________ Last __________________________
Applicant Information
Your Name: First*________________________ Middle _____________ Last*_________________________
If funeral home employee, add business name: _________________________________________________
Mailing Address*: ____________________________________________ŝƚLJ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
State: ____ͺͺͺͺͺͺͺͺͺͺͺŝƉĐŽĚĞ͗ͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ŵĂŝůĚĚƌĞƐƐ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Daytime Phone*: (__ __ __) __ __ __-__ __ __ __ ĂƚĞŽĨŝƌƚŚΎ͗ͺͺͺͺͬͺͺͺͺͬͺͺͺͺͺͺͺͺ
Relationship to Person Named on Certificate*
☐ Self (BC only)
☐ Spouse
☐ Child
☐ Parent
☐ Sibling
☐ Grandparent
☐ Legal Guardian
☐ Court Appointed Executor or Administrator
☐ Petitioner for Decedent’s Estate (DC only)
☐ Legal Representative (for one of the above)
☐ Authorized by Court Order (must present
document)
☐ Authority for Final Disposition (DC only)
☐ Social Security Administration (DC only)
☐ U.S. Department of Veterans Affairs (DC only)
☐ Deceased’s Insurance Carrier (DC only)
1
149 Church St.
Burlington, VT 05401
802-865-7000
REQUEST FOR A CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE
Identification Document(s)*:
Choose one (1) primary document or two (2) alternate documents that you are providing with this request.
Primary Document
☐ U.S. issued Driver’s License or ID Card
☐ U.S. Territories Driver’s License or ID Card
☐ Tribal ID Card containing your signature
☐ U.S. Military ID Card containing your signature
☐ Passport: U.S. or Foreign issued
☐ VISA: U.S. issued and included within a Passport
containing your signature
☐ U.S. Resident Alien Card or U.S. Green Card or
U.S. Permanent Resident Card (Form I-551)
☐ U.S. Employment Authorization Document or
Card (Form I-765)
Document # ________________________________
Expiration Date: __ __/__ __/__ __ __ __
Alternate Documents
These two documents together must contain your
current address and your signature.
☐ Employment Photo ID Card with a Pay Stub or
U.S. Internal Revenue W-2 form
☐ School, University or College Photo ID with
Report Card or other proof of current enrollment
☐ Department of Corrections ID Card with
probation documents or discharge papers
☐ Social Security or Medicare Card with your
signature
☐ Pilot’s License
☐ Car Registration or Title with current address
☐ U.S. Selective Service Card
☐ Voter’s Registration Card
☐ Filed Federal Tax Form with current address and
signature
☐ Bank Statement or Utility Bill (gas, water,
electric, sewer, phone) with current address
☐ U.S. or State Court documents with current
address
Order Summary
Total Number of Copies Requested: ______ x $10.00 each = Order Total: $ __________________
Make checks or money orders (U.S. funds) payable to __________________________________. Mail your
payment with this form and a self-addressed envelope to _______________________________________.
Or bring this completed form with your payment to _____________________________________________.
Verification
Any person who knowingly makes a false statement, misrepresentation or certification as to any material
fact on this application shall be fined not more than $10,000 or imprisoned for not more than six months or
both. 18 V.S.A. § 131(c).
I certify that the information provided on this form is true and I am eligible to receive a certified copy.
Signature*: ______________________________________________ Date Signed*: __ __/__ __/__ __ __ __
Print Name*:
FOR OFFICE USE ONLY:
ID checked and validated by: Date:
CID: CPA-B: CPA-E: Fee enclosed: $ Check Number:
2
City of Burlington
City of Burlington, 149 Church St. Burlington, VT 05401
City Hall, Clerk/Treasurer's Office, 149 Church St., Burlington, VT 05401
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Application for Certified Copy of Vermont Birth or (City of Burlington)

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Completed 16 January 2021

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