Macomb County Clerk Carmella Sabaugh’s Vital Records Certified Copy Order Form Complete and fax to the Macomb County Clerk Vital Records Office (586) 469-4751 Or mail to: Macomb County Clerk’s Office, Attn: Vital Records, 40 North Main Street, Mount Clemens, MI 48043 REQUESTOR’S INFORMATION PRINT LEGIBLY Name: Daytime Phone Number: Mailing Address: City, State, Zip: Driver’s license number: Signature (required): BUSINESS REGISTRATION BIRTH RECORDS (Copy of picture ID MUST be included) Name of Business: Name of person on record Cost: Date of Birth Additional copies: Place of Birth TOTAL: $15.00 x $5.00= $ $ Mother’s full maiden name Father’s full name DEATH RECORDS Relationship to person: Self Parent Name of Deceased Other (document proof of relationship is required) $15.00 Cost: Additional copies: Date of Death: Place of Death: TOTAL: $15.00 Cost: x $5.00= $ Additional copies: $ TOTAL: x $5.00= $ $ MARRIAGE LICENSES MILITARY DISCHARGE Bride’s Full Maiden Name: (Copy of picture ID MUST be included) Groom’s Full Name: Name Date of Marriage: $15.00 Cost: Additional copies: x $5.00= $ TOTAL: Date of Birth Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Cost: Number of copies: $ x $1.00= $ PAYMENT / MAIL INFORMATION Type of credit card being used: (If mailing, check or money order can be enclosed) COSTS (from above): $ SHIPPING: VISA Overnight*: $24.00 Regular mail: FREE TOTAL COST: (optional) $ Cardholder name (PRINT) MasterCard Discover American Express Credit Card Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Expiration Date: ___ ___ - ___ ___ Cardholder signature (REQUIRED) *Delivery may take up to 2 days depending on the zip code and if request is not received before 1 pm. Rates are higher outside of the U.S. For help completing this form call: (586) 469-5205 For additional forms: In Michigan – (888) 99-CLERK Out-of-State – (310) 575-5035 Fax-on-Demand Doc #3010 Rev. 10/09 American LegalNet, Inc. www.FormsWorkFlow.com