Birth Certificate Request Form

PLEASE RETURN THIS FORM TO: VITAL RECORDS, 2600 SKYLAND DRIVE, NE, ATLANTA, GA 30319
Please indicate below the type and number of copies requested and forward this form with either a money order or certified check for the
correct amount, made payable to Vital Records.
[

] Full size copy $25.00
Additional copies
$5.00 each at this time

[

] Photocopy of valid photo ID

[

] Total number of copies
Requested

[

] Amount Received
$_____________

BIRTH CERTIFICATE REQUESTS
FILL IN INFORMATON BELOW CONCERNING PERSON WHOSE BIRTH CERTIFICATE IS REQUESTED
Name at birth:______________________________________________________________________________________________________
(first)
(middle)
(last)
Date of birth:_________________________________________ Age: __________________ Race: _________________ Sex: ___________
Place of birth:______________________________________________________________________________________________________
(hospital)
(city)
(county)
(state)
Full name of father: _________________________________________________________________________________________________
Full name of mother before marriage: ___________________________________________________________________________________

DEATH CERTIFICATE REQUESTS
FILL IN INFORMATION BELOW CONCERNING DECEDENT
Name: ___________________________________________________________________________________________________________

Date of death:________________________________________ Age: __________________ Race: _________________ Sex: ___________
Place of death:_____________________________________________________________________________________________________
(hospital)
(city)
(county)
(state)
If married, name of husband or wife: ___________________________________________________________________________________
Occupation of deceased:_____________________________________________________________________________________________
Funeral director’s name:_____________________________________________________________________________________________
Name of doctor: ___________________________________________________________________________________________________
Place of burial: ____________________________________________________________________________________________________
(city)
(county)
(state)

MAILING ADDRESS
List below the name and address of the person to whom the certificate is to be mailed and indicate their relationship to the person whose
name is on the certificate:
Name:_________________________________________________________________ Relationship: _______________________________
Address: __________________________________________________________________________________________________________
(No. & Street or RFD and Box No.)
(Apt. No.)
__________________________________________________________________________________________________________
(city)
(state)
(zip code)
Phone: ________________________________________________