Birth Certificate Request Form

Town of West Hartford
Town Clerk - Vital Statistics
50 South Main Street
West Hartford, CT 06107
(860) 561-7430

Dear Town Clerk:

Please provide me with a certified copy of a birth certificate. Enclosed is a (__ ) money order / (__ ) personal (payable to the Town of West Hartford) and a photocopy of my driver's license.

 

Birth certificate for:

.

My relationship to this individual:

.

Date of birth:

.

Place of birth:

.

Individual's mother's maiden name:

.

Please check one:

Full size copy:______________ $10 each

Wallet size copy:______________ $5 each

 

_________________________________
Signature

 

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