ࡱ> molq` GbjbjqPqP @b::   DDD8|d <+*"*"*"*"=#% &*******$,h4/*E &9#=#&&* *"*"*'''&d *" *"*'&*''V 6 '*" 0eD&v'' +0<+'/q'/'/ '(&&'&&&&&**q'^&&&<+&&&& D D  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 is issued to those individuals who have a direct link to the individual(s) named on the vital record event, provided that the requestor is able to identify the vital record. 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 PRINT OR TYPE. ALL ITEMS ARE REQUIRED UNLESS NOTED OTHERWISE.* PROOF OF IDENTITY IS REQUIRED. MAKE CHECK OR MONEY ORDER PAYABLE TO "STATE REGISTRAR." DO NOT MAIL CASH. Name of Applicant  FORMTEXT      Relationship to Person Named On Requested Record)  FORMTEXT      Why is record being requested?  FORMCHECKBOX Passport  FORMCHECKBOX Driver License  FORMCHECKBOX School/Sports  FORMCHECKBOX Social Security Card  FORMCHECKBOX Soc. Sec. Disability  FORMCHECKBOX Other Soc. Sec. Benefits  FORMCHECKBOX Veterans Benefits  FORMCHECKBOX Medicare  FORMCHECKBOX Welfare  FORMCHECKBOX Genealogy  FORMCHECKBOX Other (Specify):  FORMTEXT      Street Address  FORMTEXT      City State Zip Code  FORMTEXT      Telephone Number  FORMTEXT      Signature of ApplicantDate of Application  FORMTEXT      B I R T HFull Name of Child at Time of Birth  FORMTEXT      No. of Copies Requested  FORMTEXT      Place of Birth (City, Town or Township)  FORMTEXT      County  FORMTEXT      Exact Date of Birth  FORMTEXT      Name of Hospital (Optional)  FORMTEXT      Mother's Full Maiden Name  FORMTEXT      Father's Name (if recorded on the record)  FORMTEXT      If Child's Name Was Changed, Indicate New Name and How It Was Changed  FORMTEXT      m a r r i a g eName of Husband  FORMTEXT      No. of Copies Requested  FORMTEXT      Maiden Name of Wife  FORVghuv{  n r t Ⱥ}fYE'jth)o5CJOJQJUhh)o5CJOJQJh,jh)o5CJOJQJUhmHnHu'jh)o5CJOJQJUh!jh)o5CJOJQJUhh)oCJOJQJhh)o5CJOJQJhh)o56CJOJQJhh)oCJOJQJhh)oCJOJQJh)o6CJOJQJh)oCJOJQJh)oCJOJQJh)o4V  r v z `$1$If^ $1$If  <$1$If^  $1$If$ @@1$]@^@a$$ d1$]^a$$ x1$]^a$P GGG  * , . 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Multiple years may be searched at a fee of $1.00 per additional year searched. 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