Department of Health, Welfare and Human Services

LOUIS E. ANELLO
ROSE S. VIRGADAMO
DIRECTOR OF HEALTH
REGISTRAR
Department of Health, Welfare and Human Services
204 HILLSIDE AVENUE ● LIVINGSTON, NJ 07039
www.livingstonnj.org
973-535-7961
Please complete the form below to receive a certified copy of a vital record. A DMV photo ID of yourself or two forms of ID with your
name and current address are required. A fee of $15.00 cash or money order to be paid at time of request.
If you choose to mail in your request, you must include a self-addressed, stamped return envelope. Copy of a DMV photo ID with
current address on the front or two forms of ID with name and current address are required, along with payment of $15.00 per copy,
money order only. Please make money order payable to “Township of Livingston”.
Name of Applicant
(Nombre de Aplicante)
Relationship to person on
record (proof may be
required).
Current Mailing Address – Must match address on ID
[Relación al individuo (Pueden
ser necesarias pruebas).]
(Dirección Postal – Debe coincidir con identificación)
Reasons for Request:
(Motivo de solicitud)
Passport (Pasaporte)
Driver’s License (Licensia de Conducir)
School / Sports (Escuela / Deportes
Veterans’ Benefits (Beneficios Veteranos)
Social Security Card
City
State
Zip Code
Daytime Telephone Number
(Ciudad)
(Estado)
(Codigo Postal)
(Número Telefónico)
(Tarjeta Seguro Social)
Social Security Disability
(SSI / Incapacidad)
Other SS Benefits
Applicant’s Signature
Date of Application
(Firma del Aplicante)
(Fecha)
BIRTH
(NACIMIENTO)
(Otros beneficios de seguro social)
Medicare (Medicare)
Welfare (Asistencia Pública)
Other (Otro)
Full Name of Child at Time of Birth
No. Requested Copies
(Nombre Completo al Nacer)
(No. de Copias)
Place of Birth (City / Town)
County
Exact Date of Birth
[Lugar de Nacimiento (Ciudad /Pueblo)]
(Condado)
(Fecha de Nacimeniento)
Full Name of Child’s Parent A
Full Name of Child’s Parent B
(Nombre completo de Padre/Madre A)
(Nombre complete de Padre/Madre B)
If the Child’s Name was Changed, Indicate New Name and How it was Changed:
(Si el nombre del niño fue cambiado, indique el Nuevo nombrey como fue cambiado):
Full Name of Spouse A/Partner A (List name given at birth or on birth certificate)
No. Copies Requested
(MATRIMONIO)
[Nombre de Esposo/Pareja (Inscrito en el acta de nacimiento)]
(No. de Copias)
CIVIL UNION
Full Name of Spouse B/Partner B (List name given at birth or on birth certificate)
Exact Date of Event
[Nombre de Esposo/Pareja (Inscrito en el acta de nacimiento)]
(Fecha Exacta del Evento)
Place of Event (City / Town)
County
[Lugar del Evento (Ciudad /Pueblo)]
(Condado)
Name of Deceased
No. Requested Copies
(Nombre del Fallecido)
(No. De Copias)
MARRIAGE
(UNIÓN CIVIL)
DOMESTIC
PARTNERSHIP
(SOCIEDADA
DOMÉSTICA)
DEATH
(DEFUNCIÓN)
Exact Date of Death
Place of Event (City / Town)
County
(Fecha Exacta de Evento)
[Lugar del Evento (Ciudad / Pueblo)
(Condado)
FOR TOWNSHIP USE ONLY
PAYMENT TYPE:
CASH
M/O
PAYMENT AMOUNT:
$
I.D. VIEWED: