"Application for Vital Record" - Massachusetts

Application for Vital Record is a legal document that was released by the Massachusetts Department of Public Health - a government authority operating within Massachusetts.

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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
st
150 Mount Vernon Street, 1
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.
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
st
150 Mount Vernon Street, 1
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.