Birth Certificate Order Form

Birth certificates are available from the Department of Health only for births which occurred within the past five years. After five years, the records are transferred to the Division of Public Records.

• How to order Vital Records from the Division of Public Records

To order a birth certificate from the Department of Health:

• Complete the application below
• Print it on your local printer.
• Sign and date the application
• Return it with your check or money order to the address below.
  Make checks or money orders payable to: Vermont Department of Health. Do NOT mail cash.

Send to:
Vermont Department of Health
Vital Records
P.O. Box 70
Burlington, VT 05402-0070

Fees:
Certified copy: $10.00
Verification: no charge
Record Search: no charge

For more information visit: Obtaining Vital Records Home

Application for Vital Record BIRTH CERTIFICATE

For office use only ID# CPA# REC#

Request for:

Certified Copy Verification Record Search

Name on birth certificate:

Sex

F M

Date of birth:
Town or city of birth:
Name of father:
Maiden name of mother:
Your name:
Address:
Town: State:
Zip: Phone Number:
Your relationship to the person on birth certificate:

Intended use of certificate

Social Security School Enrollment Passport Driver’s License Family History Other (specify)

Date: _______________________________________

Signature: ______________________________________________________________