REQUEST FOR CERTIFIED COPY OF BIRTH CERTIFICATE

CITY OF ORANGE TOWNSHIP 29 North Day Street, Orange, NJ 07050 Office of Vital Statistics Number of copies at $15.00 per copy Total $ Cash Check# Date: Certificate Number: Date of Birth (full date required) Name at Birth Place of Birth (hospital or town) Mother’s Maiden Name Father’s Name Reason for obtaining Certificate Person requesting copy:

Name Address City State Zip Telephone Number Relationship to person on Certificate Must have same name or show proof of relationship, i.e. if married, enclose copy of marriage license. Please enclose the following with your request:

• Copy of photo driver’s license with current address OR

• Two (2) other forms of ID such as

• Utility bill, lease, deed, tax return, telephone bill, bank statement

• Fee cash, money order or check

Please Note: Only IMMEDIATE relative may obtain certified copy. Relative must have proof of relationship and ID.

Mail to: City of Orange Township

Vital Statistics

29 North Day Street

Orange, New Jersey 07050

For Further Questions, please call the Office of Vital Statistics: 973-***-**** Driver’s Lic. # Passport #