s:\clerks_admin\forms\vital_records_order_form.docx Rev. 02/18/20 (rs)
Macomb County Clerk & Register of Deeds Fred Miller
Vital Records Certified Copy Request Form
Submit to the Macomb County Clerk Vital Records Office
120 North Main Street, Mount Clemens, MI 48043 Fax: (586) 469-5123 E-mail: vitalstaff@macombgov.org
BUSINESS REGISTRATION
Name of Business:
Cost: $15.00
Additional copies: x $5.00= $
TOTAL: $
MILITARY DISCHARGE
(Copy of requestor’s photo ID MUST be included)
Name
Date of Birth
Number of copies: $ FREE
MARRIAGE LICENSES
Applicant 1 (name on Application):
Applicant 2 (name on Application)::
Date of Marriage:
Cost: $15.00
Additional copies: x $5.00= $
TOTAL: $
DEATH RECORDS
Name of Deceased
Date of Death:
Place of Death:
Cost: $15.00
Additional copies: x $5.00= $
TOTAL: $
REQUESTOR’S INFORMATION
PRINT LEGIBLY
Name: Daytime Phone Number:
Mailing Address: City,
State, Zip:
Driver’s license number: E-mail
address:
Name
of person on record
Date of Birth Place of Birth
Mother’s full maiden name
Father’s full name
Relationship to person: □Self □Parent □Heir □Legal Guardian
□Legal Representative □Court of competent jurisdiction
Cost: $15.00
Additional copies
: x $5.00= $
TOTAL: $
PAYMENT / SHIPPING INFORMATION
COSTS (from above): $ If paying by credit card, please enter information below:
SHIPPING: (order is mailed to requestor’s address) Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ _
_
□ Express Mail**: $24.00 (optional - U.S. only) Expiration Date: ___ ___ - ___ ___ CSC ___ ___ ___ (security code on back of card)
□ Regular mail: FREE Billing Zip Code: ___ ___ ___ ___ ___
TOTAL COST: $ Cardholder Printed Name: Signature
(required):
Payment type: □ □ □ □
□check made payable to: Macomb County Clerk
**Delivery may take up to 2 days depending on the zip code and if request is not
received before 10 am. Include prepaid express envelope if shipping outside U.S.
BIRTH RECORDS
(Copy of requestor’s photo ID MUST be included)
