Town Clerk
Registrar of Vital Statistics
42C North Street
Goshen, Connecticut 06756
860-491-3647
_________________________________________________________
NOTE: Legal fee for vital record copies is $20.00 for each full size certified copy and $15.00 for each wallet sized.
Number of Full Sized Copies _____ X $20.00/ copy = Total $ ____________**
Number of Wallet Sized Copies _____ X $15.00/ copy = Total $ ____________**
FULL NAME AT BIRTH (FIRST MIDDLE LAST NAME):
______________________________________________________________________________
DATE OF BIRTH: __________________________________
PLACE OF BIRTH: ________________________________________
FATHER’S FULL NAME: ________________________________________________________
MOTHER’S FIRST NAME & MAIDEN NAME: _______________________________________
PERSON MAKING THIS REQUEST:
NAME:_________________________________________________________________________
STREET ADDRESS: ______________________________________________________________
TOWN / CITY:_____________________________________ STATE:____________________________ZIP CODE:_____________
TELEPHONE #_________________________
SIGNATURE: ____________________________________________________________________
RELATION TO PERSON NAMED IN CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: _____________________________________________________________________________
*Note that the wallet size birth certificate contains less information than the full size certificate. It may not satisfy all proof of
identification requirements such as those needed to obtain passports.
REQUESTER MUST ATTACH A COPY OF PICTURE IDENTIFICATION AND VERIFICATION OF RELATIONSHIP TO REGISTRANT
FEE: $20.00 FOR FULL SIZE AND $15.00 FOR WALLET SIZE PER COPY.
MONEY ORDER MADE PAYABLE TO THE GOSHEN TOWN CLERK.
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