GOGEBIC COUNTY
200 North Moore Street, Bessemer, MI 49911 (906) 663-4518
APPLICATION FOR A CERTIFIED COPY OF A VITAL RECORD
Complete this section for a Birth Record
1. Name at Birth:__________________________________________________________________
2. Date of Birth:___________________________________________________________________
3. Place of Birth:__________________________________________________________________
4. Mother’s Name (Maiden): ________________________________________________________
5. Father’s Name: ________________________________________________________________
6. My relationship to person in line 1:_________________________________________________
Signature__________________________________________________________Date______________
Complete this section for a Marriage or Death Record
Document Requested (Check one) Marriage__________ Death ____________
1. Names on Document:_____________________________________________________________
2. Date of Marriage/Death:__________________________________________________________
Signature__________________________________________________________Date_______________
FEES
First certified copy of each vital record is $10.00. Each additional copy of same record is $5.00
Number of copies requested: Birth _____ Marriage_____ Death______
Mailing address: Contact number:
________________________________ ____________________________________
________________________________ Notes:
________________________________ ____________________________________
________________________________ ____________________________________
Please make checks payable to Gogebic County Clerk
email: rdeeds@gogebic.org fax: (906) 663-4660
