The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
150 Mount Vernon Street, 1
st
Floor
Dorchester, MA 02125-3105
617-740-2600
APPLICATION FOR VITAL RECORD
(Please print legibly.)
Please fill out and return this form to the address above, along with a stamped, self-addressed, business-letter-sized envelope, proof of
identification for the person making the request and a check or money order for $32.00 for each record. Make checks payable to the
Commonwealth of Massachusetts. DO NOT SEND CASH THROUGH THE MAIL. If the date of event is unknown provide us with a ten-
year period that you would like us to search. Please enclose a photocopy of a government issued ID with your order.
BIRTH RECORD Number of copies:_____________
Name of Subject:__________________________________________________________________________________________________________
(first) (middle) (last)
Date of Birth: City or Town of Birth:
Mother's Name:____________________________________________________________________________________________________________
(first) (middle) (maiden) (last)
Father's Name:____________________________________________________________________________________________________________
(first) (middle) (last)
MARRIAGE RECORD Number of copies:______________
PARTY A:____________________________________________________________________________________________________________
(first) (middle) (last/maiden)
PARTY B:____________________________________________________________________________________________________________
(first) (middle) (last/maiden)
Date of Marriage: City or Town of Marriage:
DEATH RECORD Number of copies:______________
Name of
Deceased:____________________________________________________________________________________________________________
(first) (middle) (last) (maiden, if applicable)
Spouse's
Name:_______________________________________________________________________________________________________________
(first) (middle) (last) (maiden, if applicable)
Social Security Number (if known):
Date of Death: City or Town of Death:
Father's Name:____________________________________________________________________________________________________________
(first) (middle) (last)
Mother's Name:____________________________________________________________________________________________________________
(first) (middle) (maiden) (last)
Relationship of requestor to subject(s) named on record:__________________________________________________________
Mail record to:
Address:
City/State/ZIP Code:
Your signature:
Date of request:_________________________________________________
month/day/year
PLEASE NOTE: The earliest records available from this office are for calendar year 1926.
