Mount Holly Township
Office of Vital Records
Post Office Box 411
Mt. Holly, NJ 08060
(609) 267-0170 Ext. 312 or 314
REQUEST FOR A CERTIFIED VITAL RECORD
Your Name: __________________________________ Signature: ___________________________________

                           PLEASE HAVE YOUR PHOTO ID READY !!

Address: ___________________________________________________ Telephone # ___________________
City: ________________________________ State: _________________ Zip Code: __________________
Relationship to person named in request ____________________________________________________
Complete the appropriate section IN FULL:
FOR A BIRTH CERTIFICATE:                                          Number of Copies:_________
Full name of child at birth: _______________________________________________________________
Date of Birth: ______________________________________ Place of Birth: ______________________
Mother's full Maiden name: _________________________________________________________________
Father's Name: _____________________________________________________________________________
New name if child's name was changed: ______________________________________________________
FOR A MARRIAGE/DOMESTIC PARTNERHIP RECORD:                        Number of Copies:_________
Name of Husband/Partner A: _________________________________________________________________
Maiden name of Wife/Partner B: _____________________________________________________________
Place of Marriage/Domestic Partnership: ____________________________________________________
Date of Marriage/Domestic Partnership: _____________________________________________________
FOR A DEATH CERTIFICATE:                                          Number of Copies:_________
Name of Deceased: __________________________________________________________________________
Date of Death: _______________________________________ Age at death: _______________________
Fathers name: _________________________________ Mothers name: ______________________________
Residence at time of death: ________________________________________________________________
Do you require Cause of Death on the certificate?            Yes _____             No ______

WE DO NOT ACCEPT PERSONAL CHECKS! PLEASE, CASH OR MONEY ORDER (MADE OUT TO MT. HOLLY TOWNSHIP) ONLY.

COST IS $15 ($25 for overnight services - must provide a paid self-addressed return mailer). ADDITIONAL COPIES OF THE SAME RECORD ORDERED AT THIS TIME ARE $5 EACH.

NAME CHANGES MUST BE DOCUMENTED.

VALID PHOTO ID WITH SIGNATURE & CURRENT ADDRESS - OR TWO OTHER FORMS OF ID MUST BE PRESENTED. IF MAILING, SEND A PHOTOCOPY OF YOUR ID ALONG WITH A SELF-ADDRESSED STAMPED ENVELOPE. ADDRESS ON ID MUST MATCH RETURN ADDRESS.