DELAWARE HEALTH
AND SOCIAL SERVICES                     TELEPHONE  (302) 744-4549
Division of Public Health                                     

OFFICE OF VITAL STATISTICS 
JESSE S. COOPER BLDG 
417 FEDERAL ST.
DOVER, DELAWARE 19901

CREDIT CARD ORDERS VIA THE INTERNET:    WWW.VITALCHEK.COM


Application for a Certified Copy of a Delaware Birth Certificate

													
Please print and complete all items requested below as accurately as possible.
Name on Birth Certificate 										
		                 First Name		      Middle Name		    Last Name
                                                                                                                       (Maiden Name if Female)
Sex:	0  Male  0Female
Date of Birth 	   /	  /	

Place of Birth                   _______________________________________________________________
                                         City                              State                      (Hospital if Known)
Maiden Name of Mother	  								____________
			    First Name	             Middle Name		Maiden Name (required)
Name of Father											______
			First Name		Middle Name		Last Name
													
The birth certificate is for (please check one box)
1. 0 Myself
5. 0 I am the Legal Guardian
7. 0 Genealogy 
2. 0 Current husband or wife
6. 0 I am the Authorized agent, attorney
(proof required)
3. 0 Child 
or legal representative of  the 

4. 0 Parent 
Person listed in 1-6. (proof required)

       

Number of copies requested:  					
													
Cost:  10.00 each        (if record is not located, fee will be retained for search).
             Make Checks or Money Orders payable to the “Office of Vital Statistics”

Please include a copy of your Official Valid Photo Identification (Drivers license, 
State ID or Work ID)  Parents Identification needed for children.

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.
							
Signature of person applying for certificate
Street Address:						
City/Town:			State:			
Zip Code:  			


				
Date
(	)			
Daytime telephone Number

				
Identification (for office use only)