Macomb County Clerk Vital Records Certified Copy Request Form Submit to the Macomb County Clerk Vital Records Office 0 North Main Street, Mount Clemens, MI 48043 Fax: (877) 443-9505 E-mail: vitalstaff@macombgov.org Rev. For help completing this form call: Phone: (586) 469 - 5205 BUSINESS REGISTRATION Name of Business: Cost: $15.00 Additional copies: x $5.00= $ TOTAL: $ MILITARY DISCHARGE (Copy of requestor222s photo ID MUST be included) Name Date of Birth Number of copies: $ FREE MA RRIAGE LICENSES pplicatDate of Marriage: Cost: $15.00 Additional copies: x $5.00= $ TOTAL: $ DEATH RECORDS Name of Deceased Date of Death: Place of Death: Cost: $15.00 Additional copies: x $5.00= $ TOTAL: $ REQUESTOR222S INFORMAT ION PRINT LEGIBLY Name: Daytime Phone Number: Mailing Address: City, State, Zip: Driver222s license number: E-mail address: BIRTH RECORDS (Copy of requestor222s photo ID MUST be included) Name of person on record Date of Birth Place of Birth Mother222s full maiden name Father222s full name Relationship to person: Self Parent Heir Legal GuardianLegal Representative Court of competent jurisdiction Cost: $15.00 Additional copies: x $5.00= $ TOTAL: $ PAYMENT / SHIPPING INFORMATION COSTS (from above): $ If paying by credit card, please enter information below: SHIPPING: (order is mailed to requestor222s address) Number - - - Overnight*:$24.00 (optional) Expiration Date: - CVV (security code on back of card) Regular mail:FREE Billing Zip Code: TOTAL COST: $ Cardholder Printed Name: Signature (required): Payment type: check made payable to Macomb County ClerkPICK UP OPTION: Check here if you222d like to pick this order up at our office.If the order will be picked up by someone other than the requestor, please provide *Delivery may take up to 2 days depending on the zip code and if .... that person222s name: . request is not received before 1 pm . Rates are higher outside of the U.S. Photo ID is required for pickup (by requestor or person named above). American LegalNet, Inc. www.FormsWorkFlow.com