Birth Certificate Request (PDF)

*If adopted, please provide your adoptive name and adoptive parents’ information.
 VS-39B REV 12/21 
*If you had your name legally changed, please provide a copy of the court documents authorizing the name change.
REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE TOWN 
Mail this request to the Town Vital Records office.  For the address and phone number of Town Vital 
Records offices in Connecticut, please refer to our website at www.ct.gov/dph. 
PLEASE PRINT 
FULL NAME ON CERTIFICATE*:________________________________________________________________________________ 
 FIRST 
 MIDDLE  
 LAST NAME 
DATE OF BIRTH:  ________/________/________ 
 PLACE OF BIRTH:  _____________________________________________ 
 MONTH  
 DAY  
  YEAR  
 TOWN/CITY 
MOTHER/PARENT:  ____________________________________________________________________________________________ 
 FIRST  
 MIDDLE  
  LAST NAME(Include name prior to first marriage if applicable) 
FATHER/PARENT:  _____________________________________________________________________________________________ 
 FIRST  
 MIDDLE  
  LAST NAME(Include name prior to first marriage if applicable) 
PERSON MAKING THIS REQUEST: 
NAME:  ________________________________________________________________________________________________________ 
 FIRST  
 MIDDLE  
 LAST NAME 
ADDRESS:  _____________________________________________________________________________________________________ 
  NUMBER/STREET/UNIT # 
TOWN/CITY:  __________________________________________________   STATE:  _____________  ZIP CODE:  _____________ 
TELEPHONE NO:  ____________________________________   E-MAIL ADDRESS:  ______________________________________ 
SIGNATURE:  X_________________________________________________________________________________________________ 
RELATION TO PERSON NAMED ON CERTIFICATE:  ______________________________________________________________ 
REASON FOR MAKING REQUEST:  ______________________________________________________________________________ 
CERTIFICATE SIZE: 
  FULL SIZE 
  WALLET SIZE 
TOTAL NUMBER OF COPIES: 
$20.00 EACH 
NUMBER OF COPIES:  __________ 
The wallet size birth certificate contains less 
information than the full size certificate.  It 
may not satisfy all proof of identification 
requirements such as those needed for a 
passport. 
$15.00 EACH 
NUMBER OF COPIES:  __________ 
_______  X  $20.00  =  $  _______ 
_______ X  $15.00  =  $  _______ 
TOTAL:  $ _______ 
PLEASE DO NOT MAIL CASH. 
Attach a copy of the requester’s valid government issued photo 
ID or passport below: 
Or two (2) forms of the following: 
-
Social security card
-
Written verification of identity from employer
-
Automobile registration
-
Copy of utility bill showing name and address
-
Voter’s registration card
Please make sure to mail the completed request with the 
following requirements: 
  Check or Money order made payable to:
 WATERFORD TOWN CLERK 
TOWNCLERK
  Current government issued photo ID 
  (If applicable) verification of relationship to the 
registrant 
     (for example, an individual requesting his/her parent’s 
     birth certificate must provide a certified copy of his/her 
own birth certificate) 
SIGN