Rev. June 2021
OFFICE OF VITAL STATISTICS
JESSE S. COOPER BLDG.
417 FEDERAL STREET
DOVER , DE 19901
(302) 744-4549
CHOPIN BUILDING
258 CHAPMAN RD.
NEWARK, DE 19702
(302) 283-7130
THURMAN ADAMS STATE SERV CTR.
546 S. BEDFORD ST.
GEORGETOWN, DE 19947
(302) 856-5495
CREDIT CARD ORDERS VIA GOCERTIFICATES or VITALCHEK
APPLICATION FOR A CERTIFIED COPY OF A DELAWARE BIRTH CERTIFICATE
PLEASE COMPLETE ALL ITEMS REQUESTED BELOW AS ACCURATELY AS POSSIBLE.
Name on Birth
Certificate
First Name
Middle Name
Last Name on Birth Certificate
Sex Male Female
Date of Birth (mm/dd/yyyy)
Place of Birth
City
State
Hospital if Known
Name of Mother or
Name of Parent A
First Name
Middle Name
Last Name on Birth Certificate
Name of Father or
Name of Parent B
First Name
Middle Name
Last Name on Birth Certificate
Number of copies requested: ____________
RELATIONSHIP TO THE PERSON WHOSE BIRTH CERTIFICATE YOU ARE REQUESTING (PLEASE CHECK ONE BOX)
Myself My current husband or wife*
My child My parent*
Other* _________________________________
(Specify familial relationship)
I am the legal guardian (court order required)
Genealogy (proof required)
I am the authorized agent, attorney or legal
representative of the person listed in 1-6 options
(proof required)
*Proof of relationship (eg. birth or marriage certificate)
For Authorized Representatives:
Client’s Name: ________________________________
Client’s Relationship to Registrant: ________________
Purpose:_________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Note: Additional documentation may be requested.
REQUIRED UPON FILING OF APPLICATION
1. Cost: $25.00 per copy (If record is not located, fee will be retained for search). Make checks or money orders payable
to the Office of Vital Statistics.
2. Copy of your official valid photo identification (Drivers license, State ID, Work ID or passport).
3. Parent’s identification needed for children.
PERSON APPLYING FOR CERTIFICATE
I hereby certify that all the above information is true to the best of my knowledge. It is a felony violation of Delaware Law
(16 Del. C.§3111) to make a false statement on this application or to unlawfully obtain a certified copy of a birth certificate.
Print name of person applying for certificate
Signature of person applying for certificate
Date
Street Address
City/Town
State/Zip Code
Email Address
Daytime Phone
FOR OFFICE OF VITAL STATISTICS USE ONLY
Identification:
