Township of Warren

Board of Health

Office of the Registrar

Somerset County

46 Mountain Boulevard, Warren, New Jersey 07059-5695

908-753-8000 Extension 239 – (Fax) 908-757-9173

AFFIDAVIT TO OBTAIN CERTIFIED

COPIES OF BIRTH CERTIFICATES

Fee:      $10.00 per copy

REQUESTORS MUST BE ABLE TO IDENTIFY A RECORD OF BIRTH

BY PROVIDING EXACT INFORMATION

NAME:  ____________________________________________________________

             EXACT NAME AS IT IS SHOWN ON THE BIRTH RECORD – (FIRST, MIDDLE, LAST)

PLACE OF BIRTH: __________________________________________________

                              THE EXACT PLACE WHERE THE BIRTH EVENT OCCURRED (CITY)

DATE OF BIRTH _____________________________________________________

                           THE EXACT DATE THE BIRTH EVENT OCCURRED (MONTH, DAY, YEAR)

MOTHER’S MAIDEN NAME: ____________________________________________

                                            THE MOTHER’S FULL  MAIDEN NAME 

FATHER’S NAME: ____________________________________________________

                             THE FATHER’S FULL NAME

NUMBER OF COPIES:  _________

PURPOSE FOR WHICH CERTIFICATE IS NEEDED:

______________________________________________________________________

YOUR NAME:________________________________________________________________________

                        PLEASE PRINT

YOUR ADDRESS: ____________________________________________________________________

                               ____________________________________________________________________

                            CITY                                                                              STATE                                      ZIP CODE

YOUR TELEPONE NUMBER:   (________)_________________

                                                AREA CODE

YOUR RELATIONSHIP TO ABOVE NAMED: ______________________________________________ _

YOUR SIGNATURE:___________________________________________________________________

                                                                                                                                DATE      

OFFICE USE ONLY

IDENTIFICATION PROVIDED      __________________________________________________

(1 REQUIRED IF PHOTO 2 REQUIRED IF NO PHOTO)           _______________________           

RECEIPT NUMBER:  _______________________  CHECK OR CASH:    ___________________

CERTIFICATE NUMBER(S) _______________________________________________________

PERSON PREPARING CERTIFIED COPY: ___________________________________________