Town of East Hartford
Registrar of Vital Statistics
740 Main Street
East Hartford, CT 06108
(860) 291-7230
APPLICATION FOR BIRTH CERTIFICATE
□ FULL-SIZE COPY - $20.00
□ WALLET-SIZE COPY - $15.00
(Exact copy of original for Social Security, Passport, DMV, etc.)
(Contains only basic information.)
VALID GOVERNMENT-ISSUED PHOTO IDENTIFICATION OF APPLICANT IS REQUIRED
Photographic identification may be substituted by at least two of the following documents:
automobile registration, copy of utility bill showing name and address, checking account deposit slip
stating name and address or any other valid government-issued ID.
I am applying for the birth certificate of:
Full Name _____________________________________
□ My own birth certificate
Date Of Birth ___________________________________
□ My child’s birth certificate
Place Of Birth __________________________________
□ My parent’s birth certificate
Father’s Full Name ______________________________
□ My grandparent’s birth certificate
Father’s Birthplace ______________________________
□ My spouse’s birth certificate
Mother’s Maiden Name ___________________________
□ My grandchild’s birth certificate
Mother’s Birthplace ______________________________
□ Other _______________________
(C.G.S. § 19a-25; 7-51a; 7-44
as amended by P.A. 01-163)
SIGNATURE of Applicant ____________________________________________________________
ADDRESS of Applicant ___________________________________ Phone # ___________________
If requesting by mail, include: (1) Completed application form, (2) check or money order, (3) Self-addressed,
stamped envelope, (4) legible copy of photo ID. Mail to the address above.
Make check payable to “East Hartford Town Clerk.”
FOR OFFICE USE ONLY:
Date certified copy issued: ___________________ Person issuing copy: ______________________________________
Form(s) of identification used: _________________________________________________________________________
