Colorado Denver Application Birth Certificate Form – Fill Out and Use This PDF

DENVER HEALTH

Denver Vital Records

605 Bannock St. Room 302 Denver, Colorado 80204-4507

303- 602-3660

www.denverhealth.org/vitalrecords

Application for Certified Copy of Birth Certificate

Denver County Vital Records has birth records for the entire state since 1907.

Information about person whose birth certificate is requested — please type or print. IF ADOPTED , provide adoptive information.

			First				Middle		Last (s)
Full name at birth
Date of birth	Month		Day		Year			Yes □	No □
						Is this person deceased?
						If yes, date: ____/____/____		State where death occurred: ____________________
								Please provide copy of death certificate
Place of birth				City				C o u n t y
Full name of father			First				Middle		Last (s)
			First				Middle		Maiden (s)
Maiden name of mother:
Certificate needed for

Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1 ,000.00, or imprisonment in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118)

By signing below, I have read and understood that there are penalties for obtaining a record under false pretenses.

Effective 7/1/2003, all requests must be accompanied by a copy of the requestor's identification before processing. Please return your request with a copy of your driver's license, state ID or passport. See reverse side for additional accepted documents.

Signature of person making request		Relationship to registrant*		Driver's License #	State of License		Expiration Da te
Address	City	State	Zip		Daytime Phone
					(	)

 Apply in person for same day service. Office hours are from 8: 0 0 a.m. to 4.00 p.m., Monday-Friday.

 Order certificates online* at www.VitalChek.com. Certificates mailed within 2 to 5 days business days via regular mail, UPS 1 to 2 business days.

 Fax your application with credit card information**: fax 303-602-3665

 Mail in application with check, money order, or credit card information **. Certificate (s) mailed within 3 to 4 weeks via regular mail. * * Convenience charge to be added. See charges below.

Credit card orders:

Card Type:	VISA	MasterCard	Discover
Cardholder name:___________________________________________________________				Total copies ordered
Card Number:	______________________________________ Exp Date ________

c

S t a

Make check or money order payable to Vital Records Section. Please do not send cash.

PLEASE COMPLETE THIS AREA

PRINT name and address of person making request:

Name

Address

City/State/Zip

**Charges

Cost of certificates ($17.75 for 1st copy or search when no record found); $10 for each additional copy of same record ordered at same time) .....................

Convenience charge (credit card orders

$10.00) Walk in excluded .....................

*UPS Service with

CREDIT CARD ORDERS ONLY ($19)

Total Charges.......................................

*Within continental U.S.

$

$_________

$ ________