REQUEST FOR VITAL RECORD
Print This Form
In order to request a birth, marriage or death certificate, please fill in the appropriate section
below; send this form, together with a check for $8.00 for each certificate requested
and a self-addressed stamped envelope to: The Milton Town Clerk's Office, 525 Canton Avenue
Milton Massachusetts 02186.
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I WISH TO REQUEST A BIRTH CERTIFICATE FOR:
Name of Child: ___________________________________________
Date of Birth: ___________________________________________
Place of Birth: ___________________________________________
Fathers Name: ___________________________________________
Mothers Name: ___________________________________________
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I WISH TO REQUEST A MARRIAGE CERTIFICATE FOR:
Groom's Name: ___________________________________________
Brides Name: ___________________________________________
Date of Marriage: __________________________________________
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I WISH TO REQUEST A DEATH CERTIFICATE FOR:
Name of Deceased: ____________________________________
Date of Death: ____________________________________
Spouses Name: ____________________________________
Fathers Name: ____________________________________
Mothers Name: ____________________________________
Please mail above certified copies to:
Name: __________________________________________________
Address: __________________________________________________
City/State/Zip: __________________________________________________
Number of Copies Requested @ $8.00 each: __________________________
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