Application for Certified Copy of Vermont Birth or Death Certificate - Form Template

Sep 17, 2026

Uploaded by Aria

Application form for requesting a certified copy of a Vermont birth or death certificate. Captures applicant identity and contact details, including required fields marked with asterisks, and collects essential certificate information such as dates and towns of birth/death, sex, and parental names. Includes sections for the requester’s relationship/authority, required identification document submissions per Vermont statute, order copy counts with payment details, verification statements, and official-use fee and ID validation fields.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Applicant's Information

Certificate Information

Your Relationship to the Person Named on the Certificate

Order Details & Payment

Applicant's Identification Document(s)

Verification & Signature

Mail and Office Use Only

Insert Logo Here Application for Certified Copy of Vermont Birth or Death Certificate | Items with an Asterisk (*) are REQUIRED information.

Applicant's Information*:
Your Name: First*: Middle: Last*: Suffix: Business Name: Mailing Address*: City*: State*: Zip Code*: Date of Birth*: / /
Phone Number *: ( ) - Email Address:

Certificate Information*:
I am requesting a (choose one)*:
Birth Certificate Date of Birth*: / / Town of Birth* Is this a Certificate of Birth for a Foreign-Born Child?
Yes No
Death Certificate
Date of Death* : / / Town of Death *
Name on Certificate: First* : Middle: Last*: Suffix: Sex*: Male Female
Name of Mother/Parent: First: Middle: Last: Suffix:
Name of Father/Parent: First: Middle: Last: Suffix:

Your Relationship to the Person Named on the Certificate (choose one)*: | | --- | |
Self (BC Only) Authorized By Court Order

Spouse Pursuant to 18 V.S.A. § 5016(b)(2)(B) .
Child Must provide a certified copy of court order.
Parent Photo copies will not be accepted.
Sibling Authority for Final Disposition (DC Only)
Grandchild Social Security Administration (DC Only)
Grandparent U.S. Department of Veterans Affairs (DC Only)
Legal Guardian Deceased's Insurance Carrier (DC Only)
Court Appointed Executor or Administrator Employee of a Vermont public agency authorized
Petitioner for Decedent's Estate (DC Only) pursuant to 18 V.S.A. § 5016(a)(6) .
Legal Representative (for one of the above) | | Application continues on page 2. | July 2021 page 1 of 2 | Order Details*: | | | | | --- | --- | --- | --- | | Total number of copies requested: x $10.00 each = Order Total: $ Make checks or money orders (U.S. funds) payable to: | | | | | Applicant's Identification Document(s)* | | | | | As per Vermont Statute, a copy of your valid ID MUST be submitted with your application. Submit a copy of one of the documents listed below. Fill in the ID number and expiration date of the selected ID you are providing.
Document \#: Expiration Date: / / | | | | |
U.S. issued Driver’s License or ID Card
U.S. Territories Driver’s License or ID Card
Tribal ID Card containing your signature
U.S. Military ID Card containing your signature Passport: U.S. or Foreign issued
VISA: U.S. issued and included within a Passport | | | U.S. Resident Alien Card or U.S. Green Card or
U.S. Permanent Resident Card (Form I-551)
U.S. Employment Authorization Document or Card | | | |
(Form I-765)
Valid State of Vermont Employee ID"Affidavit of Homeless Status" form **
Documentation from Vermont Department of | | | containing your signature
** -Does not require document number or expiration date | | | | | | | Corrections substantiating identity ** | | | If you do not have one of the above ID's, you must submit copies of two documents from the list below.
These two documents together must show your current address and your signature.
Only the documents listed below are acceptable forms of alternative ID. | | | | | | Employee Photo ID Card with a Pay Stub or |
Car Registration or Title with current address U.S. Selective Service Card
Voter's Registration Card
Filed Federal Tax Form with current address | | | | U.S. Internal Revenue W-2 Form
School, University or College Photo ID with Report Card or other proof of current enrollment Federal or State Corrections or Prisons issued ID Social Security or Medicare Card with your signature
Pilot's license | | | | | | and signature | | | | | | Bank Statement, Property or Utility Bill with | | | | current address | | | | | | U.S. or State Court documents with current address | | Verification*: | | | | | Any person who knowingly makes a false statement, misrepresentation or certification as to any material fact on this application shall be fined not more

FAQs

What information is required to request a certified birth or death certificate in Vermont?

The form requires applicant identification and contact details, the type of certificate requested, relevant dates and towns, and key name and (for death certificates) sex information. Required fields are marked with an asterisk.

What documents must be submitted with the application?

A copy of a valid identification document must be provided according to the Vermont statute. If the applicant does not have the listed ID types, two alternative documents showing the current address and signature are required.

How are authorized requesters identified on the form?

The form requires the requester to select a relationship/authority category (such as self, parent, spouse, legal guardian, or other DC/B C only options) that matches the situation and provides the correct basis for authorization.

Sep 17, 2026

Uploaded by Aria