OFFICE OF VITAL STATISTICS
417 FEDERAL STREET
DOVER, DELAWARE  19901
			
							Today's Date_______________
							Number of Copies___________


ADOPTEES APPLICATION FOR COPY OF ORIGINAL BIRTH CERTIFICATE
COMPLETE ALL ITEMS REQUESTED BELOW AS ACCURATELY AS POSSIBLE

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Full Name at Birth (If known)			       Full Name Given You Upon Adoption     

   _______________________________________________________________________________________
Date of Birth (Month, Day, Year)		       Place of Birth (Hospital)

   ________________________________________________________________________________________
Birth Mother's Full Maiden Name (If known)	       Birth Father's Full Name (If Known)

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Adopted Mother's Full Maiden Name		       Adopted Father's Full Name



PHOTO IDENTIFICATION MUST BE PRESENTED
To Vital Statistics verifying that you are indeed
The adoptee who is named above.


______________________________________________
Name

______________________________________________
Street/Development/Rural Delivery/Box Number

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City/Town

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State 		   Zip Code

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Daytime Telephone Number


FEE:	$10.00

Payable to the OFFICE OF VITAL STATISTICS

**PLEASE BE AWARE THAT THIS PROCESS CAN TAKE UP TO TWO MONTHS**