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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.
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
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.
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