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BIRTH

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					Newark
Department of Child and Family Well-Being Vital Statistics 920 Broad Street, Room 111 Newark, New Jersey 07102 (973) 733-6510

For Birth Certificate Only OMB-1208-102

Page 1 of 1

Do not apply here unless affidavit occurred in Newark, NJ. Do not request certificate unless you have legal right to it: IDENTIFICATION REQUIRED.
Certified copies are $25.00 for the 1st copy and $4.00 each additional copy of the same record.

Full name of person

Did birth occurr in Newark, NJ?
Yes

No

(If not in Newark, do not apply)

Date of Birth

Sex

Select One

Full name of father

Full maiden name of mother

Name and address of person requesting certificate

Relationship or authorization

Date of application

DO NOT FILL BELOW THIS LINE
Certificate No. Filing date No. of years searched

Not found

Yes
Searcher Date

No