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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 $5.00 for each certificate requested

and a self-addressed stamped envelope to: The Randolph Town Clerk's Office, 41

South Main Street, Randolph, MA 02368.  Fill in your name and address at the bottom of

this sheet.  If the record is restricted (parents were not married at time of birth, father not

named, or in case of a marriage if parents were not married at the time of the birth of the

bride or groom); please send a photocopy of your driver's license; since only those named

on the certificate have a right to said document.

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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: __________________________________________

NOTE: Marriages are recorded where the bride and groom applied for their license

NOT where they got married.

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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 @ $5.00 each:  __________________________