Wayne County, Michigan


NAME AT BIRTH [First, Middle, Last]

DATE OF BIRTH [ Month, Day,Year]		CITY OF BIRTH *excluding Detroit - Births taking place within the City Limits of Detroit are recorded by the: :: city of detroit health dept. » ::

MOTHER'S MAIDEN NAME [First, Middle, Last]

FATHER'S NAME [First, Middle, Last]

What is your relationship to the person in line 1? [Mother, Father, Self]
*Include a Photocopy of requestor's valid I.D.
	Applicant's Name

	Address

	City, State, Zip

	Phone [Area Code + Number]

	Applicant's Signature [Name as it is now] Date

Please send the following: _____ FIRST CERTIFIED COPY $22.00 _____ Additional certified copies [each] $7.00 [of the same record] _____ Senior Citizen [65+] $2.00 _____ TOTAL COST
Make money order, cashier's check, or certified check [no personal checks] payable to :
	Wayne County Clerk c/o Birth and Death Records Division 201 Coleman A. Young Municipal Cntr Detroit, MI 48226