Application for Certified Copy of Vermont Birth or Death Certificate
* = Required Field
January 2020
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 at Birth (surname): ______________________________________________________________
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_________________________
State: ____ͺͺͺͺͺͺͺͺͺͺͺŝƉĐŽĚĞ͗ͺͺͺͺͺͺͺͺͺͺ Date of Birth*: __ __/__ __/__ __ __ _
Daytime Phone*: (__ __ __) __ __ __-__ __ __ __ Email Address: ____________________________
Applicant's Relationship to Person Named on Certificate*
Self (BC only)
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
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)
149 Church St.
Burlington, VT 05401
(802) 865-7000
Request for a Certified Copy of a Vermont Birth or Death Certificate
Applicant's Identification Document(s)*:
Submit a copy of one (1) of these documents
Or submit copies of two (2) of these documents
These 2 documents together must show 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
Federal or State ID issued by departments,
bureaus, or agencies of corrections or prisons
Social Security or Medicare Card with your
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
Bank Statement, Property or Utility Bill with
current address
U.S. or State Court documents with current
Total Number of Copies Requested: ______ x $10.00 each = Order Total: $ __________________
Make checks or money orders (U.S. funds) payable to
Mail payment with this completed form, copy of identification
and a self-addressed envelope to:
Or bring completed form, identification and your payment to:
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*:
ID checked and validated by: Date:
CID: CPA-B: CPA-E: Fee enclosed: $ Check Number:
Order Summary
"Affidavit of Homeless Status" form
Documentation from Vermont Department of
Corrections substantiating identity
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)
Valid State of Vermont Employee ID
Document # ______________________________
Expiration Date: __ __/__ __/__ __ __ __
City of Burlington
City of Burlington, 149 Church St., Burlington, VT 05401
City Hall, Clerk/Treasurer's Office, 149 Church St., Burlington, VT 05401