Request For Birth Certificates: Number of copies _______ at $20.00/copy = $ ________ Name: ________________________________________ Date Of Birth: ________________________________________ Father's Name: ________________________________________ Mother's Maiden Name: ________________________________________ Reason For Obtaining Certificate: ________________________________________ Person Requesting Document: ________________________________________ Address: ________________________________________ ________________________________________ Phone: ________________________________________

Please submit the following with your request:

• Copy of identification showing your name and address
• Self addressed stamped envelope
• Request fee of $20.00 - Cash or Money Order (made out to Glen Ridge Board of Health) only. No personal checks.

Send your request to:
Vital Statistics
PO Box 66
Glen Ridge, New Jersey 07028