Application for Certified Copy of Birth Certificate Still Birth

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					         Colorado Department of Public Health and Environment                                                                                           For Office Use Only
                                            Vital Records Section HSVR-VR-A1                                                                            ID        _____               Cash        _____
                                              4300 Cherry Creek Drive South                                                                             ISS       _____               CK          _____
                                                  Denver, CO 80246-1530                                                                                                               CC          _____
                                                      (303)692-2200                                                                                                                   Other       _____
                                                www.cdphe.state.co.us/certs
                                                                                                                                                        SF#       _____-____________

Application for Certified Copy of Birth Certificate
            Colorado has birth records for the entire state since 1910. Certified copies of certificates are also available from county offices (see reverse side).

Requestor Information
Print name of person making request            First                    Middle                                          Last                          Reason for request:

Mailing Address                                          City                                 State                     Zip                           Daytime Phone
                                                                                                                                                      (      )
Physical Address                                         City                                 State                     Zip                           Alt Phone Number
                                                                                                                                                      (      )

Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and
tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or imprisonment
in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118)

PLEASE RETURN YOUR REQUEST WITH A PHOTOCOPY OF YOUR DRIVER’S LICENSE, STATE ID OR PASSPORT.
(To review the full list of primary and secondary identification, please visit www.cdphe.state.co.us/certs)
 By signing below, I have read and understood that there are penalties for                                         Relationship to Registrant (person                        Today’s date
 obtaining a record under false pretenses.                                                                         named on certificate) *see reverse side


                                                                                                                   Please submit proof of relationship

Registrant Information
Information about person whose birth certificate is being requested — please type or print.
If adopted, provide adoptive information and see special service on other side.
 Full Name at Birth First                                             Middle                               Last

                            Month Day Year                            Is this Person Deceased? ❒Yes                      ❒No            If yes, date: ____/____/_______
Date of Birth
                                                __ __ __ __                                               State Where Death Occurred: _________________________
                                                                                                          Please provide certified copy of death certificate
                            City                                      County                                         State
Place of Birth
                                                                                                                              Colorado ONLY
Full Name of Father         First                                     Middle                                         Last

                            First                                    Middle                                              Maiden Last Name (name prior to first marriage)
Full Name of Mother
  ❒ Check here if you are requesting a certificate of stillbirth
 Ways to Order                                                                                 Charges
 Apply in person for same-day service. Office hours are from 8:30 a.m. to 4:30
     p.m., Monday–Friday.                                                                      Cost of certificates:
 Order certificate online** at www.cdphe.state.co.us/certs Certificate(s)                           $17.75 for 1st copy (or search when no record found)                               $
     mailed 2-3 days after receipt of all required documentation.
                                                                                                      $10 for each additional copy of same record ordered
 Fax your application with credit card information**: within continental U.S.                         at same time .............................................................       $
      fax 1-800-423-1108; outside continental U.S. fax 1-303-691-9307.
      Certificate(s) mailed at the end of five business days upon receipt of all                      $9 credit card convenience charge (walk-ins excluded)                            $
      required documentation.
 Mail in application with check, money order, or credit card information. Make check                  $50 for each heirloom copy .....................................                 $
      or money order payable to Vital Records. Please do not send cash. Certifcate(s)
      mailed within three weeks upon receipt of all required documentation.                    Please check one:
                                                                                                    ❒ Regular mail ($0.00 - no additional charge for regular
 **$9.00 convenience charge to be added.                                                            mail)
                                                                                                    ❒ Fed Ex – within continental U.S. ($20.00)
                                                                                                    ❒ Express Mail – within continental U.S. ($17.50)                                  $
Credit Card Orders**                                                                           Total ..............................................................................    $
Card Type: ❒ Visa           ❒ Mastercard ❒ Discover               ❒ American Express
Cardholder Name:___________________________________________                                                  Number of standard copies
                                                                                                             Number of heirloom copies
Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
                                                                                                             Total copies ordered
                      Exp. Date: _____/_________
**$9.00 convenience charge to be added.                                                                                                                                                    07/10 bicert.pdf
*Certified copies of birth certificates may be issued to:
         Please note that proof of relationship is required: (e.g. marriage certificates, birth certificates, court orders)
                       The registrant (person named on the certificate)                                       Adult children or grandchildren of the registrant
                       Parents                                                                                Stepchildren
                       Grandparents and Great grandparents                                                    Legal guardian
                       Stepparents                                                                            Legal representatives of any of the above must present proof of client relationship
                       Siblings                                                                               Consular Corps
                       Spouse                                                                                 Genealogists representing family members with appropriate credentials
Certified copies of certificates are available in the county where birth occurred. The following county offices can issue certified copies for birth occurring anywhere in Colorado for birth years 1910 to present.

         COUNTY OFFICES:                                                                  Fremont County Local Registrar                                          Morgan County
         Alamosa County Registrar                                                         Mr. Ray Woodard                                                         Northeast Colorado Health Department
         Courthouse                                                                       611 Main Street                                                         228 W. Railroad
         402 Edison Avenue                                                                P.O. Box 872                                                            Fort Morgan, CO 80701
         P.O. Box 630                                                                     Canon City, CO 81215-0872                                               970-867-4918
         Alamosa, CO 81101                                                                719-275-1556                                                            Fax: 970-867-0878
         719-589-6681                                                                     Fax: 719-276-5123
         Fax: 719-589-6118                                                                rdwoodard1@yahoo.com                                                    Otero County Health Department
         dheiman@alamosacounty.org                                                                                                                                13 West Third Street, Room 111
                                                                                          Garfield County                                                         La Junta, CO 81050
         Archuleta County                                                                 109 8th Street Suite 200                                                Phone 719/383-3040,
         San Juan Basin Health Department                                                 Glenwood Springs, CO 81601                                              FAX 719/383-3060
         P.O. Box 597                                                                     970-945-2377 x1950
         Pagosa Springs, CO 801147                                                                                                                                Park County Clerk and Recorder
         970-264-4640                                                                     Grand County Courthouse                                                 501 Main Street P.O. Box 220
                                                                                          308 Byers Ave. P.O. Box 120                                             Fairplay, CO 80440
         Baca County                                                                      Hot Sulphur Springs, CO 80451                                           phone 719.836.4333
         Office of the Treasurer                                                          970-725-3347 ext.110                                                    fax 719.836.4348
         741 Main Street                                                                  Fax: 970-725-0100                                                       email: pcclerk@amigo.net
         Springfield, CO 81073
         719-523-4302                                                                     Gunnison County Registrar                                               Prowers County Nursing Service
                                                                                          Dept. of Public Health                                                                   .O.
                                                                                                                                                                  1001 S. Main St P Box 336
         Bent County Nursing Service                                                      225 North Pine St. Ste. E                                               Lamar CO 81052
         701 Park Avenue                                                                  Gunnison, CO 81230                                                      719-336-2606
         Las Animas, CO 81054                                                             970-641-0209                                                            Fax: 719-336-2985
         719-456-6042
         Fax: 719-456-0518                                                                Jefferson County Vital Records                                          Pueblo County Health Department
         dlucero@bcns.net                                                                 Dakota Building                                                         101 W. 9th St.
                                                                                          800 Jefferson County Parkway, Suite 1300                                Pueblo, CO 81003
         Boulder County Public Health                                                     Golden, CO 80401                                                        719-583-4300 (press 4)
         3450 Broadway                                                                    303-271-6450
         Boulder, CO 80304                                                                Fax: 303-271-6451                                                       Rio Grande County
         303-441-1100    Fax: 303-440-3984                                                                                                                        Office of the Clerk and Recorder
                                                                                          Kit Carson County                                                       965 6th Street, PO Box 160
         Boulder County Public Health                                                     251 16th Street                                                         Del Norte, CO 81132
         529 Coffman, Suite 200                                                           Burlington, CO 80807                                                    719 -657-3334
         Longmont, CO 80501                                                               719-346-5950
         303-678-6166     Fax: 303-678-6163                                                                                                                       Routt County Northwest Colorado Visiting Nurses Assn.
                                                                                          La Plata County                                                         940 Central Park Drive Suite 101
         Broomfield Department of Health and Human Services                               San Juan Basin Health Dept                                              Steamboat Springs, CO 80487
         6 Garden Center                                                                  281 Sawyer Dr., Suite 300                                               9708791632
         Broomfield, CO 80020                                                             Durango, CO 81303
         720-887-2270                                                                     970-247-5702                                                            San Miguel County Registrar
         Fax: 303-469-2110                                                                Fax: 970-247-9126                                                       Office of the Treasurer
                                                                                                                                                                  P.O. Box 488
         Chaffee County                                                                   Lake County                                                             Telluride, CO 81435-0488
         City of Salida                                                                   115 E 5th Street                                                        970-728-4451
         448 E. 1st Street, Ste. 112                                                      PO Box 24
         Salida, CO 81201                                                                 Leadville, CO 80461                                                     Sedgwick County
                                                                                          719-486-0708                                                            Sedgwick County Treasurer
         Cheyenne County                                                                                                                                          315 Cedar, Suite 210
         Cheyenne County Public Health                                                    Larimer County Health Department                                        Julesburg, CO 80737
         615 North 5th West                                                               1525 Blue Spruce Drive                                                  970-474-3473
         PO Box 38                                                                        Fort Collins, CO 80524                                                  Fax: 970-474-0954
         Cheyenne Wells, CO 80810                                                         970-498-6710
         719-767-5616                                                                     Fax: 970-498-6715                                                       Summit County Clerk & Recorder
         Fax: 719-767-8747                                                                                                                                        P.O. Box 1538
                                                                                          Las Animas County Health Dept.                                          Breckenridge, CO 80424
         Crowley County Local Registrar                                                   412 Benedicta Ave.                                                      970-453-3475
         603 Main, Ste 2                                                                  Trinidad, CO 81082-2095                                                 Fax: 970-453-3540
         Ordway, CO. 81063                                                                719-846-2213
         719-267-5222                                                                                                                                             Teller County Clerk & Recorder
         Fax: 719-267-3114                                                                Logan County                                                            101 W. Bennett Ave.
                                                                                          Northeast Colorado Health Department                                    P.O. Box 1010
         Delta County Registrar                                                           700 Columbine                                                           Cripple Creek, CO 80813
         Office of the Clerk and Recorder                                                 Sterling, CO 80751-0316                                                 719-689-2951
         501 Palmer St. Ste. 211                                                          970-522-3741                                                            Fax: 719-686-8030
         Delta, CO 81416-1796                                                             Fax: 970-522-1412
         970-874-2150                                                                                                                                             Tri County Health Department
                                                                                          Mesa County Health Department                                           (Adams, Arapahoe and Douglas County)
         Denver Vital Records                                                             510 29½ Rd                                                              7000 East Belleview, Suite 301
         605 Bannock Street                                                               PO Box 20000                                                            Englewood, CO 80111-1628
         Denver, CO 80204-4507                                                            Grand Junction, CO 81502-5033                                           303-220-9200
         303-602-3660                                                                     970-248-6900                                                            Fax: 303-221-2906
         Fax: 303-602-3665                                                                Fax: 970-248-6972
                                                                                          Karen.Armstrong@mesacounty.us                                           Washington County NE Colorado Health Dept.
         Eagle County Health and Human Services                                                                                                                   150 Ash St.
         P.O. Box 660                                                                     Moffat County Northwest Colorado Visiting Nurses Association            Akron, CO 80720
         551 Broadway                                                                     745 Russell St.                                                         970-345-6562
         Eagle, CO 81631                                                                  Craig, CO 81625                                                         Fax: 970-345-6561
         970-328-8840                                                                     9708248233
                                                                                                                                                                  Weld County Health Department
         Elbert County                                                                    Montezuma Couny Clerk & Recorder                                        1555 N. 17th Avenue
         33817 Blue Bird Lane                                                             109 West Main, Room 108                                                 Greeley, CO 80631
         Elizabeth, CO 80107                                                              Cortez, CO 81321                                                        970-304-6410
         303-646-4127                                                                     970-565-3728                                                            Fax: 970-304-6412
         Fax: 303-646-0446                                                                Fax: 970-564-0215
                                                                                                                                                                  Weld County Health Department
         El Paso County Health Department                                                 Montrose County Clerk & Recorder                                        4209 WCR 24½
         305 South Union Boulevard                                                        320 S. 1st Street, Room 101                                             Longmont, CO 80504
         Colorado Springs, CO 80910-3123                                                  P.O. Box 1289                                                           720-652-4240 ext 8842
         719-575-8492                                                                     Montrose, CO 81402                                                                                   Yuma County- Wray
         Fax: 719-575-8493                                                                970-249-3362                                                            Yuma County                  245 West 4th St
                                                                                                                                                                  910 South Main               Wray, CO 80758
                                                                                                                                                                  Yuma, CO 80759               970-332-4431
                                                                                                                                                                  970-848-3878                 Fax: 970-332-0691
                                                                                                                                                                  Fax: 970-848-5101
 OPTION AVAILABLE FOR ADOPTIONS:
   Sign below only if you wish "ISSUED PURSUANT TO ADOPTION" to appear on your certified copy of the birth certificate. Only an adoptive parent or adopted
   person is eligible for this special service effective August 8, 2002.

       Number of copies without "issued pursuant to adoption" requested:
       Number of copies with "issued pursuant to adoption" requested:                                                                 Signature of :                                            x
                                                                                                                                                       adopted person             adoptive parent
                                                                                                                                                          (relationship to registrant; check one)

				
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Description: Application for Certified Copy of Birth Certificate Still Birth