New Hampshire Department of State

Division of Vital Records Administration

71 South Fruit Street

Concord, NH 03301-2410

APPLICATION FOR COPY OF BIRTH CERTIFICATE

PLEASE PRINT

NAME AT BIRTH _________________________________________________________

(First Name) (Middle Name) (Last Name)

DATE OF BIRTH _____________________________________________________________

(Month) (Day) (Year)

PLACE OF BIRTH ____________________________________________________________

FATHER’S NAME ____________________________________________________________

(First) (Last)

MOTHER’S MAIDEN NAME ___________________________________________________

(First) (Last)

NUMBER OF COPIES REQUESTED _________ (First copy $12; each additional copy will be issued for $8)

PURPOSE FOR WHICH CERTIFICATE IS REQUESTED? _______________________________

SIGNATURE____________________________________________________

PRINTED NAME ________________________________________________

ADDRESS ______________________________________________________

PHONE NUMBER _______________________________________________

RELATIONSHIP TO THE REGISTRANT__________________________________________

THE LAW FOR THE SEARCH OF THE FILE REQUIRES A FEE OF TWELVE DOLLARS FOR ANY ONE RECORD. IF WE FIND THAT RECORD AND YOU MEET NEW HAMPSHIRE’S ACCESS REQUIREMENTS, YOU WILL BE ISSUED ONE CERTIFIED COPY OF THAT CERTIFICATE.

Notice: Any person shall be guilty of a Class B Felony if he/she willfully and knowingly makes any false statement in an application for a certified copy of a vital record. (RSA 126:24)

DCN #’s ISSUED:

DATE ISSUED: