APPLICATION FOR COPIES OF VITAL RECORDS
Sharon Lear Willoughby, Pender County Register of Deeds
PO Box 43 Burgaw, NC 28425 910-259-1225
Complete Appropriate Sections: (Print or Type)
Certified Copies are $10/each
Uncertified Copies are $1.00/each
Cash, Check or money order accepted
Full Name at Birth:
First Middle Last
Place of Birth Date of Birth:
(Hospital or City/County)
Father’s Full Name:
Mother’s Full Maiden Name
Maiden name of mother is required
□Certified #copies _________
□ Uncertified #copies _________
Full Name of Deceased:
First Middle Last
Date of Death:
Location of Death (City/County):
□Certified #copies _________
□ Uncertified #copies _________
Full Name of Spouse 1:
First Middle/Maiden Last
Full Name of Spouse 2:
First Middle/Maiden Last
Date of Marriage:
Location of Marriage (City/County)
□Certified #copies _________
□ Uncertified #copies _________
Your Relationship to the Person Whose Certificate is Requested: (Check One)
□ 1. Self □ 5. Parent/Step-Parent
□ 2 Spouse □ 6. Grandparent/Grandchild
□ 3. Brother/Sister □ Seeking information for legal determination of personal or property rights
□ 4. Child/Step-Child □Authorized agent, attorney or legal representative of the person listed in 1-6
(Proof Required)
I certify that all the above information that I have provided is true to the best of my knowledge. Note: It is a felony violation of
North Carolina Law to make a false statement on this application or to unlawfully obtain a certified copy of a birth certificate.
_________________________________________________ _____________________________________
Signature of Person Requesting Certificate Printed Name of Person Requesting Certificate
_________________________________________________ ____________________ (____)_____________________________
Physical Street Address Date Telephone Number
_________________________________________________
City, State and Zip Code
B C
D C-
M C
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Office Use Only
Type of ID Presented _________________
Book/Page __________________________
Certificate # _________________________
Office Use Only
Type of ID Presented _________________
Book/Page __________________________
Certificate # _________________________
Office Use Only
Type of ID Presented _________________
Book/Page __________________________
Certificate # _________________________
A picture ID is required for certified copies.
For requests by mail: Include a self-addressed, stamped envelope. If requesting a certified copy, include a copy of your current driver’s license, state
-issued ID or other approved photo ID.
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