Date

Department of Vital Statistics
Address
City, State

Records Clerk:

I need to obtain a copy of my birth certificate. I was born as (give birth name) at (name and address of hospital) on (give date of birth). (1-4 below)

I am enclosing a check for (or money order) in the amount of (amount of stipulated by state)

Sincerely,

(your signature, using BIRTH NAME)

(DO NOT STATE ADOPTION AT ALL)

other possible Inclusions for above:

1. Add: My mother's name was (if known).
2. Add: I was born at (give time if known).
3. Add: I weighed (give weight if known).
4. Add Due to a separation in our family, I am unable to supply
you with all necessary facts.

This letter must be notarized.

For those of you who do not know what agency handled your adoption please see:
Letter for Adoptee Referring to a State Agency for aid in Location of Local or Private Agency Records