Application for Certified Copy of Vermont Birth or Death Certificate
Insert Town Name
Insert Town Address
Insert Town Address
* = 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
27 West Allen Street
Winooski, VT 05404
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