Georgia Birth & Death Certificate Request Form
Print out a copy, complete, and mail in your request.

Please indicate below the type and number of copies requested and forward this form with
either a money order or certified check for the correct amount, made payable to the
Georgia Department of Human Resources.

[   ] Full size copy $10.00 [   ] Wallet size copy $10.00 [   ]  Total Number of Copies Requested
[   ] Additional Copies Requested

Additional copies are $5.00 each at this time    Requested $_____________

BIRTH RECORDS ONLY

Fill in information below concerning person whose birth certificate is requested

Name at birth:__________________________________________________________________

(first) (middle) (last)

Date of birth:_______________ Age:_________ Race:_________ Sex:________

Place of birth:______________________________________________________________

(hospital) (city) (county) (state)

Full name of father:__________________________________________________________

Full name of mother before marriage:____________________________________________

DEATH CERTIFICATE REQUESTS

Fill in information below concerning decedent

Name:_____________________________________________________________________

Date of death:_____________________ Age:_________ Race:__________ Sex:_________

Place of death:______________________________________________________________

(hospital) (city) (county) (state)

If married, name of husband or wife:__________________________________________

Occupation of deceased:_____________________________________________________

Funeral director's name:______________________________________________________

Name of doctor:____________________________________________________________

Place of burial:_____________________________________________________________

(city) (county) (state)

MAILING ADDRESS

List below name and address of person to whom certificate is to be mailed and
indicate their relationship to the person whose name is on the certificate.

Name:________________________________ Relationship:______________

Address:____________________________________________________________

(No. & Street or RFD and Box No.) (Apt No.)

_____________________________________________________________

(city) (state) (zip code)