REQUEST FOR CERTIFIED COPY OF A BIRTH RECORD
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF VITAL RECORDS
SFN 8140 (07-2019)
PLEASE PRINT - ALL ITEMS MUST BE COMPLETED AND LEGIBLE TO LOCATE AND IDENTIFY THE RECORD
1. Full Name on Birth Record (If adopted, list adoptive name)
2. Sex
Male Female
4. Place of Birth or Death (City, Township or County)
3. Date of Birth or Death (Month, Day, Year)
5. Full Name of Father (First, Middle, Last) (If adopted, list adoptive father/parent name)
6. Full Name of Mother (First, Middle, Maiden) (If adopted, list adoptive mother/parent name)
7. Number of Certified Copies Requested ($15.00 per copy requested)
Certified (For all official purposes, including U.S. Passport, Driver’s License, etc.)
Genealogy (For researching family history - not available for births occurring after 2005)
8. Fees: (Check or Money Order)
$ .00
9. Your Relationship to Person on Line 1*
Self (must be 16 or older) Mother/Father Public (Only if record is over 125 years old) Authorized Rep (include court order)
Legal Guardian (must include guardianship papers - Social Services must also include employment photo ID)
* If individual on line #1 is deceased and you are the
spouse, parent, child, grandparent, or grandchild, you may request birth record.
You must include a certified copy of the death record.
Requestor Signature
Date
Requestor Printed Name
Daytime Telephone Number
( )
Mailing Address Apartment Number
City
State
ZIP Code
Shipping Options: (First Class Mail is the no cost default)
First Class Mail - (Free) FedEx - $16 (Add $6 for AK or HI) UPS - $16 Waive Signature for FedEx or UPS Delivery
IDENTIFICATION REQUIRED - All applicants must submit A) One Primary form of ID; OR B) Two Secondary forms of ID;
OR C) Submit a Notarized application. (Choose A or B or C) - Acceptable forms of identification listed on back of the form)
Date Subscribed and Sworn Before Me
SEAL
Signature of Notary Public
My Commission Expires
Warning - NDCC 23-02.1-32(c) Penalties. Any person who willfully or knowingly uses or attempts to use or to furnish to another for use,
for any purpose of deception, any certificate, record, report, or certified copy thereof so made, altered, amended or mutilated shall be
guilty of a class C felony.
PLEASE DO NOT ENTER ANYTHING BELOW THE LINE - THIS PORTION FOR OFFICIAL VITAL RECORDS OFFICE USE ONLY
Identification Verified Fee Received
