Request for Certified Copy of a Birth Certificate: DATE: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Check One: * Application for Birth Certificate Application for Certificate of Birth Registration (Wallet-size) I AM APPLYING FOR THE ABOVE DOCUMENT (AS CHECKED) CONCERNING THE FOLLOWING PERSON: FIRST NAME * FULL MIDDLE NAME - no initials * LAST NAME * SUFFIX DATE OF BIRTH: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 PLACE OF BIRTH: (HOSPITAL) * INFORMATION ON ABOVE PERSON'S FAMILY PARENT #1 FIRST NAME * PARENT #1 FULL MIDDLE NAME - no initials * PARENT #1 LAST (MAIDEN) NAME * SUFFIX PARENT #2 FIRST NAME * PARENT #2 FULL MIDDLE NAME - no initials * PARENT #2 LAST (MAIDEN) NAME * SUFFIX You are the registrant, and you are 18 years of age or older.You are the parent, gaurdian, grandparent, or spouse of the registrant.You are the child or grandchild of the registrant, and you are 18 years of age or older.You are an attorney-at-law representing the registrant's parent, guardian, child, or surviving spouse.You are a state or federal agency employee and have an authorized release from the registrant who is 18 years of age or older.You are the Local Director of Health of the town/city where the birth occurred or where the mother was a resident at the time of the birth.You are the chief elected offical of the town/city where the birth occurred.You are a member of an incorporated genealogical society authorized to conduct business in the State of Connecticut. (Please visit CSL History and Genealogy Unity website for more information) I CERTIFY THAT THIS IS AN APPLICATION FOR: * MY OWN BIRTH MY CHILD'S BIRTH THE BIRTH OF A CHILD FOR WHO I AM THE GUARDIAN MY GRANDCHILD'S BIRTH (SUBJECT TO PROPER INDENTIFICATION) MY GRANDPARENT'S BIRTH (SUBJECT TO PROPER INDENTIFICATION) MY SPOUSE'S BIRTH MY PARENT'S BIRTH; I AM EIGHTEEN YEARS OF AGE OR OLDER PRINT YOUR NAME: * STREET ADDRESS: * TOWN/CITY: * STATE: * ZIP CODE: * EMAIL ADDRESS: * DAYTIME PHONE NUMBER: * Upload Identification * Files must be less than 5 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Number of certified copies * Mail or In Person Pick-up Leave this field blank