Probate Court Form No. 198 Petition for Establishment of Delayed Certificate of Birth (Page 1 of 2) STATE OF VERMONT PROBATE COURT DISTRICT OF _______________________ PETITION FOR ESTABLISHMENT OF DELAYED CERTIFICATE OF BIRTH TO THE HONORABLE PROBATE COURT FOR THE DISTRICT AFORESAID: Comes ___________________________________ of _________________ County of ____________________, and State of Vermont, and that no certificate of birth for your petitioner is filedor recorded. THEREFORE, your petitioner sets forth the following facts respecting __________ birth and familyhistory, to wit: 1. Place of birth - County _____________________________ State ___________________________ Township ___________________________or Village _______________________ City __________________________ No _________ Street ____________________ (If birth occurred in a hospital or institution, give its NAME instead of street and number.) 2. Full nameof child ______________________________________________________ 3. Date of birth _________________________4. Sex ___________________________ (Month, day year) 5. FATHER 11. Full maiden name MOTHER ___________________________________ __________________________________ 6. Residence at time of birth of your petitioner12. Residence at time of birth of your petitioner ____________________________________ _________________________________ 7. Date of birth 13. Date of birth ___________________________________ __________________________________ 8. Birthplace 14. Birthplace ___________________________________ __________________________________ 9. Occupation 15. Occupation ___________________________________ __________________________________ 10. Industry or business 16. Industry or business ___________________________________ __________________________________ >>>> 2Probate Court Form No. 198 Petition for Establishment of Delayed Certificate of Birth (Page 2 of 2) 17. Date and place of marriage of parents ___________________________________________ Reasons for mkaing this application ____________________________________________ __________________________________________________________________________ __________________________________________________________________________ WHEREFORE, your petitioner prays that said Cotu, rafter due notice and hearing, find the factsrespecting the birth of your petitioner, issue a decrettine sge forth the facts found and fill out a birthcertificate in the usual form and file such certificate wit the Clerk of the - Town - City of ________________________________________ County of ____________________ and State of Vermont. Dated at ___________________, this ______ day of ____________ 20 _____. ______________________________ ,Petitioner