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Application for Vital Records

2. A certificate of a vital record event is issued to those individuals with a distant or no relationship to the individual(s) listed on the vital record It is issued for informational purposes only and cannot be used for legal or identification purposes.

4. A certified copy of a vital record event is issued to those individuals who have a direct link to the individual(s) named on the vital record event as identified in Governor McGreevey's Executive Order 18. Provided that the requestor is able to identify the vital record and can provide proof of his identity and relationship. A certified copy will contain the raised Great Seal of the State of New Jersey and can be used for legal or identification purposes.

6. Proof of identity is required for this form.
   Please make checks or money orders payable to Edgewater Board of Health. The fee is $15.

   Please make checks or money orders payable to Edgewater Board of Health. The fee is $15.

8. Name of Applicant*

9. Phone Number*

11. Relationship to Person Named On Requested Record*

    Proof may be required.

13. Address1

15. Address2

17. City

18. State

19. Zip

21. Why Is the Record Being Requested? *

    1. Drivers License
    2. Genealogy
    3. Medicare
    4. Passport
    5. School / Sports
    6. Social Security Benefits

    1. Social Security Card
    2. Social Security Disability
    3. Veterans Benefits
    4. Welfare
    5. Other

23. If Other, Please Specify

25. Signature of Applicant

26. Date of Application
    Date of Application

30. Birth Certificate

32. Full Name of Child at Birth

33. Number of Copies Requested

35. Place of Birth

36. County

38. Date of Birth
    Date of Birth

39. Name of Hospital

41. Mother's Full Name (With Maiden Last Name)

42. Father's Full Name

44. If the Child's Name Was Changed, Indicate New Name and How It Was Changed

46. Do not use this form to request a certified copy of a certificate of birth resulting in stillbirth. Use form REG-68 which is available online from the stateof New Jersey.
    http://www.nj.gov/health/forms/reg-68.pdf

    http://www.nj.gov/health/forms/reg-68.pdf

48. CERTIFICATE OF BIRTH RESULTING IN STILLBIRTH
    Form reg-68

52. Marriage or Civil Union

54. Please Choose 1

    1. Marriage Certificate
    2. Civil Union Certificate

56. Name of Husband / Civil Union partner

57. Number of Copies Requested

59. Name of Wife (with maiden name) / Civil Union Partner

60. Date of Ceremony
    Date of Ceremony

62. Place of Marriage

63. County

67. Domestic Partnership

69. Name of Partner

70. Number of Copies Requested

72. Name of Partner

73. Date Registered
    Date Registered

75. Place Where Domestic Partnership Registered

76. County

80. Death Certificate

82. Name of Deceased

83. Number of Copies Requested

85. Date of Death
    Date of Death

87. Place of Death

88. County

90. Mother's Full Name (with maiden name)

91. Father's Full Name

95. Note:
    Births occurring over 80 years ago, marriages occurring over 50 years ago and deaths occurring over 40 years ago are considered genealogical and therefore exact information is not required. You may provide only the name of the individual recorded on the vital record, the county where the event occurred and the year that the event occurred. Multiple years may be searched at a fee of $1 per additional year.

    Births occurring over 80 years ago, marriages occurring over 50 years ago and deaths occurring over 40 years ago are considered genealogical and therefore exact information is not required. You may provide only the name of the individual recorded on the vital record, the county where the event occurred and the year that the event occurred. Multiple years may be searched at a fee of $1 per additional year.

97. Payment Type

    1. Cash
    2. Check

    1. Money Order
    2. Waived

98. Payment Amount

100. ID Viewed

101. Processed By:

Leave This Blank:


103. Submit

* indicates a required field