This document is an application form for obtaining a certification or a certified copy of a vital record from the New Jersey Department of Health and Senior Services, Vital Statistics and Registration. It outlines the differences between a 'Certification' and a 'Certified Copy,' indicating which individuals are eligible for each. The form requires the applicant to provide personal information, details of the vital record event (birth, marriage, domestic partnership, or death), and the reason for the request. Proof of identity is required, and payment must be made to the Boro of Woodlynne.
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--- Document: Vital Record Document ---
New Jersey Department of Health and Senior Services
Vital Statistics and Registration
APPLICATION FOR A CERTIFICATION OR A CERTIFIED COPY OF A VITAL RECORD
A Certification of a vital record event is issued to
those individuals with a distant or no relationship
to the individual(s) listed on the vital record. It is
issued for informational purposes only and cannot
be used for legal or identification purposes.
A Certified Copy of a vital record event is issued to those individuals who have a
direct link to the individual(s) named on the vital record event, as identified in Governor
McGreevey's Executive Order 18, provided that the requestor is able to identify the
vital record and establish their identity. A Certified Copy will contain the raised Great
Seal of the State of New Jersey and can be used for legal or identification purposes.
PLEASE TYPE OR PRINT CLEARLY! ALL ITEMS ARE REQUIRED UNLESS NOTED OTHERWISE.* PROOF OF IDENTITY IS
REQUIRED. MAKE CHECK OR MONEY ORDER PAYABLE TO BORO OF WOODLYNNEDO NOT MAIL CASH.
Name of Applicant
Street Address
City
Signature of Applicant
Full Name of Child at Time of Birth
Place of Birth (City, Town or Township)
BIRTH
Relationship to Person' Named
On Requested Record
Why is record being requested?
Passport
Driver License
School/Sports
Social Security Card
Soc. Sec. Disability
Other Soc. Sec. Benefits
Veterans Benefits
Medicare
Welfare
Genealogy
Other:
State
Zip Code
Telephone Number
Date of Application
No. of Copies Requested
County
Exact Date of Birth
Name of Hospital (Optional)
Mother's Full Maiden Name
Father's Name (if recorded on the record)
If Child's Name Was Changed, Indicate New Name and How It Was Changed
DO NOT use this form to request a Certified Copy of a Certificate of Birth Resulting in Stillbirth. Use form REG-68 which is
available on the Department's website at: www.state.nj.us/health/vital/vital.shtml. Follow the instructions carefully.
Name of Husband
No. of Copies Requested
Maiden Name of Wife
Place of Marriage (City, Town or Township)
Exact Date of Marriage
County
Name of Partner
No. of Copies Requested
Name of Partner
Exact Date Registered
Place Where Domestic Partnership Registered (City, Town or Township)
County
Name of Deceased
No. of Copies Requested
Exact Date of Death
Place of Death (City, Town or Township)
County
Mother's Full Maiden Name
Father's Name (if recorded on the record)
MARRIAGE PARTNERSHIP
DOMESTIC
Processed By:
• Births occurring over 80 years ago, marriages occurring over 50 years ago and deaths occurring over 40 years ago are considered genealogical
and therefore exact information is not required. You may provide only the name of the individual recorded on the vital record, the county where the
event occurred and the year the event occurred. Multiple years may be searched at a fee of $1.00 per additional year searched.
DEATH
REG-3
MAY 04
Payment Type:
Cash
Check
DM/O
Waived
Payment Amount:
$
FOR BORO USE ONLY
ID Viewed:
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