Vital Record Correction Request Form
Submit your request to correct information on an official vital record. Please provide accurate details and supporting documentation.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Vital Record
*
Please Select
Birth Certificate
Marriage Certificate
Death Certificate
Other
Record Holder's Full Name
*
First Name
Last Name
Date of Event (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe the Error on the Record
*
Provide the Correct Information
*
Upload Supporting Documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Request
Submit Request
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