Birth Certificate Order Form

Birth certificates are available from the Department of Health only for births which occurred within the past five years. After five years, the records are transferred to the Vermont State Archives and Records Administration (VSARA).

To order a birth certificate from the Department of Health:

• Complete and print the application below.
• Sign and date the application.
• Make check or money order payable to "Vermont Department of Health".
• The fee for certified copies is $10.00 per copy.
• Return the application with your check or money order to the address below. Do NOT mail cash.

Send to:
Vermont Department of Health
Vital Records
P.O. Box 70
Burlington, VT 05402-0070

For more information visit: Obtaining Vital Records Home

Application for a Certified Copy of a Birth Certificate

For office use only ID# CPA# REC#

Number of Copies:
Amount Enclosed $
Name on Birth Certificate:

Sex

F M Date of Birth:
Town or City of Birth:
Name of Father:
Maiden Name of Mother:
Your Name:
Address:
Town: State:
Zip: Phone Number:
Your relationship to the person on birth certificate:

Intended use of certificate

Social Security School Enrollment Passport Driver’s License Family History Other (specify)

Date: _______________________________________

Signature: ______________________________________________________________