Print name of person making request First
Middle
Last
Reason for request:
Mailing Address
City
State
Zip
Daytime Phone
( )
Physical Address
City
State
Zip
Alt Phone Number
( )
Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and
tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or imprisonment
in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118)
PLEASE RETURN YOUR REQUEST WITH A PHOTOCOPY OF YOUR DRIVER’S LICENSE, STATE ID OR PASSPORT.
(To review the full list of primary and secondary identification, please visit www.cdphe.state.co.us/certs)
Credit Card Orders**
Card Type: ❒ Visa ❒ Mastercard ❒ Discover
❒ American Express
Cardholder Name:___________________________________________
Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Exp. Date: _____/_________
**$6.00 convenience charge to be added.
Colorado Department of Public Health and Environment
Vital Records Section HSVR-VR-A1
4300 Cherry Creek Drive South
Denver, CO 80246-1530
(303)692-2200
www.cdphe.state.co.us/certs
Application for Certified Copy of Birth Certificate
Colorado has birth records for the entire state since 1910. Certified copies of certificates are also available from county offices (see reverse side).
Requestor Information
Registrant Information
First
Middle
Last
Month Day Year
Is this Person Deceased? ❒Yes ❒No
If yes, date: ____/____/_______
__ __ __ __
State Where Death Occurred: _________________________
City
County
State
Colorado ONLY
First
Middle
Last
First
Middle
Maiden Last Name (name prior to first marriage)
Ways to Order
Apply in person for same-day service. Office hours are from 8:30 a.m. to 4:45
p.m., Monday–Friday.
Order certificate online** at www.cdphe.state.co.us/certs Certificate(s)
mailed next work day upon receipt of all required