Fillable Printable Birth Certificate Request Form - Georgia
Fillable Printable Birth Certificate Request Form - Georgia
Birth Certificate Request Form - Georgia
PLEASE RETURN THIS FORM TO: VITAL RE C OR DS, 2600 SKYLAND DRIVE, NE, ATLANTA, GA 30319
Please indicate below the type and number of copies requested and forward this form with either a money order or certified check for the
correct a
mount, made payable to Vital Records.
[ ] Full size copy $
25.00 [ ] Total number of copies [ ] Amount Received
Additional copies
Requested $_____________
$5.00 each at this time
[ ] Photocopy of valid photo ID
BIRTH CERTIF IC AT E REQUES TS
FILL IN INFORMATON BELOW CONCERNING PERSON WHOSE BIRTH CERTIFICATE IS R EQU ESTED
Name at birth:_____________ ____________________________________________________________ _____________________________
(first) (middle) (last)
Date of birth:_________________________________________ Age: ________________ __ Race: _________________ Sex: ___________
Place of birth:__________________________________________________________ ____________________________________________
(hospital) (city) (county) (state)
Full name of father: _____________________ ____________________________________________________________ ________________
Full name of mother before marriage: ___________________ _____________________________________________ ___________________
DEATH CERTIFICATE REQUESTS
FILL IN INFORMATION BELOW CONCERNING DECEDENT
Name: ________________ ____________________________________________________________ _______________________________
Date of death:________________________________________ Age: _____________ _____ Race: _________________ Sex: ___________
Place of death:_________________________________________________ ____________________________________________________
(hospital) (city) (county) (state)
If married, name of husband or wife: _____________________________ ______________________________________________________
Occupation of deceased:_______________________________________ ______________________________________________________
Funeral director’s na me:______ _____________________________________________ __________________________________________
Name of doctor: _______________________________________________________________________ ____________________________
Place of burial: _________________________________________________________ ___________________________________________
(city) (county) (state)
MAILING ADDRESS
List below the name and address of the person to who m the certificate is to be mailed and indicate their relationship to the person whose
name is on the certificate:
Name:________________ _________________________________________________ Relationship: ____________ ___________________
Address: _____________________________________________________ _____________________________________________________
(No. & Street or RFD and Box No.) (Apt. No.)
__________________________________________________________________________________________________________
(city) (state) (zip code)
Phone: ________________________________________________
