Form B (REG-36B) "New Records System for Birth Parents Family History Information Form" - New Jersey

What Is Form B (REG-36B)?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form B (REG-36B) by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form B (REG-36B) "New Records System for Birth Parents Family History Information Form" - New Jersey

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New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
ORIGINAL BIRTH CERTIFICATE INFORMATION
Please provide complete and accurate information. While the Department will diligently search its files for an adoption record that
matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the
information you provide in your request.
CHILD’S INFORMATION
Child’s FIRST Name on Child’s Original Birth Certificate:
Child’s MIDDLE Name on Child’s Original Birth Certificate:
Child’s LAST Name on Child’s Original Birth Certificate:
Suffix:
Child’s Date of Birth: __ __ / __ __ / __ __ __ __
Actual
Estimate
Sex:
Male
Female
Country of Birth:
State of Birth:
County of Birth:
Municipality of Birth:
MOTHER’S INFORMATION
Mother’s FIRST Name on Child’s Original Birth Certificate:
Mother’s MIDDLE Name on Child’s Original Birth Certificate:
Mother’s LAST Name on Child’s Original Birth Certificate:
Mother’s Date of Birth:
__ __ / __ __ / __ __ __ __
FATHER’S INFORMATION
Father’s FIRST Name on Child’s Original Birth Certificate:
Father’s MIDDLE Name on Child’s Original Birth Certificate:
Father’s LAST Name on Child’s Original Birth Certificate:
Father’s Date of Birth:
__ __ / __ __ / __ __ __ __
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 1 of 7.
New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
ORIGINAL BIRTH CERTIFICATE INFORMATION
Please provide complete and accurate information. While the Department will diligently search its files for an adoption record that
matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the
information you provide in your request.
CHILD’S INFORMATION
Child’s FIRST Name on Child’s Original Birth Certificate:
Child’s MIDDLE Name on Child’s Original Birth Certificate:
Child’s LAST Name on Child’s Original Birth Certificate:
Suffix:
Child’s Date of Birth: __ __ / __ __ / __ __ __ __
Actual
Estimate
Sex:
Male
Female
Country of Birth:
State of Birth:
County of Birth:
Municipality of Birth:
MOTHER’S INFORMATION
Mother’s FIRST Name on Child’s Original Birth Certificate:
Mother’s MIDDLE Name on Child’s Original Birth Certificate:
Mother’s LAST Name on Child’s Original Birth Certificate:
Mother’s Date of Birth:
__ __ / __ __ / __ __ __ __
FATHER’S INFORMATION
Father’s FIRST Name on Child’s Original Birth Certificate:
Father’s MIDDLE Name on Child’s Original Birth Certificate:
Father’s LAST Name on Child’s Original Birth Certificate:
Father’s Date of Birth:
__ __ / __ __ / __ __ __ __
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 1 of 7.
New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
BIRTH PARENT INFORMATION
NOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if
you wish to retain your privacy at this time.
Birth Parent’s Current First Name:
Birth Parent’s Current Middle Name:
Birth Parent’s Current Last Name:
Birth Parent’s Date of Birth:
__ __ / __ __ / __ __ __ __
Birth Parent’s Relationship to Child:
Mother
Father
Phone 1:
Home
Mobile
Work
Phone 2:
Home
Mobile
Work
Phone 3:
Home
Mobile
Work
Email Address:
Mailing Address:
City:
State:
Zip:
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 2 of 7.
New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
BIRTH PARENT DEMOGRAPHIC INFORMATION
Your Current Age:
Eye Color:
Blood Type:
Primary Language
Height (inches):
Hair Color
Spoken:
Nationality
Weight (lbs.)
Race:
(Citizenship):
Religion:
Skin Color:
Highest Level
Ethnic
of Education:
Background:
Your Place of Birth:
Country:
State:
City:
BIOLOGICAL INFORMATION ON DECEASED FAMILY MEMBERS
List your family members who have passed away, age at death, and cause of death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
Relationship*:
Age at Death:
Cause of Death:
*Relationship choices:
•Mother
•Son
•Maternal Grandmother
•Paternal Grandmother
•Sister
•Aunt
•Father
•Daughter
•Maternal Grandfather
•Paternal Grandfather
•Brother
•Uncle
•Other Biological Parent
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 3 of 7.
New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
MEDICAL HISTORY
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood
relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.
Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.
Note: All fields under this section are required.
HEART AND BLOOD VESSELS
Medical Condition
Response
Comments
No
Yes (Self)
Congenital Heart Defect
Not Known
Yes (Relative)
No
Yes (Self)
Congestive Heart Failure
Not Known
Yes (Relative)
No
Yes (Self)
Atherosclerosis
Not Known
Yes (Relative)
No
Yes (Self)
Hypertension (High Blood Pressure)
Not Known
Yes (Relative)
No
Yes (Self)
Stroke
Not Known
Yes (Relative)
No
Yes (Self)
Heart Attack
Not Known
Yes (Relative)
No
Yes (Self)
Other Cardiovascular Problems
Not Known
Yes (Relative)
BRAIN AND NERVES
Medical Condition
Response
Comments
No
Yes (Self)
Cerebral Palsy
Not Known
Yes (Relative)
No
Yes (Self)
Seizures, Convulsions or Epilepsy
Not Known
Yes (Relative)
LUNGS
Medical Condition
Response
Comments
No
Yes (Self)
Chronic Bronchitis
Not Known
Yes (Relative)
No
Yes (Self)
Emphysema
Not Known
Yes (Relative)
No
Yes (Self)
Asthma
Not Known
Yes (Relative)
Hay Fever or Other Allergies; Food or
No
Yes (Self)
Drug Allergies
Not Known
Yes (Relative)
No
Yes (Self)
Tuberculosis
Not Known
Yes (Relative)
KIDNEY
Medical Condition
Response
Comments
No
Yes (Self)
Kidney Disease
Not Known
Yes (Relative)
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 4 of 7.
New Jersey Department of Health
B
Vital Statistics and Registry
NEW RECORDS SYSTEM FOR BIRTH PARENTS
PO Box 370
FAMILY HISTORY INFORMATION
Trenton, NJ 08625-0370
MEDICAL HISTORY, CONTINUED
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood
relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.
Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.
Note: All fields under this section are required.
BLOOD DISORDER
Medical Condition
Response
Comments
Sickle Cell Anemia or Tay-Sachs
No
Yes (Self)
Disease
Not Known
Yes (Relative)
JOINTS / SKELETON
Medical Condition
Response
Comments
No
Yes (Self)
Scoliosis
Not Known
Yes (Relative)
No
Yes (Self)
Any Other Malformations
Not Known
Yes (Relative)
ENDOCRINE (GLANDS)
Medical Condition
Response
Comments
No
Yes (Self)
Thyroid Disorder
Not Known
Yes (Relative)
No
Yes (Self)
Diabetes
Not Known
Yes (Relative)
No
Yes (Self)
Other Hormonal Disorder
Not Known
Yes (Relative)
PSYCHOSOCIAL
Medical Condition
Response
Comments
Schizophrenia, Bipolar Disorder, or
No
Yes (Self)
Chronic Depression
Not Known
Yes (Relative)
Alcoholism, Drug Addiction
No
Yes (Self)
or Tobacco Use
Not Known
Yes (Relative)
No
Yes (Self)
Anorexia or Bulimia
Not Known
Yes (Relative)
No
Yes (Self)
Other Mental or Emotional Illnesses
Not Known
Yes (Relative)
SKIN DISORDERS
Medical Condition
Response
Comments
No
Yes (Self)
Eczema or Other Skin Conditions
Not Known
Yes (Relative)
DEVELOPMENTAL
Medical Condition
Response
Comments
No
Yes (Self)
Learning Disability
Not Known
Yes (Relative)
Mental or Physical Development
No
Yes (Self)
Deficiencies
Not Known
Yes (Relative)
No
Yes (Self)
Autism Spectrum
Not Known
Yes (Relative)
REG-36B
For questions or additional Information:
AUG 15
www.nj.gov/health/vital
866-649-8726, EXT. 582
Page 5 of 7.