Fillable Printable Application for Vital Record - Massachusetts

Application for Vital Record - Massachusetts

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

REGISTRY OF VITAL RECORDS AND STATISTICS

150 MT. VERNON STREET, 1

Floor

DORCHESTER, MA 02125-3105

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 and a check or

money order for $32.00

for each record. Make checks payable to the Commonwealth of Massachusetts. Do not submit more than 5 requests per

letter. 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.

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)

PARTY B:____________________________________________________________________________________________________________

(first) (middle) (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 1921.