Request for a copy of a birth certificate

Department of Vital Statistics
Hometown County
Hometown NY

Dear Registrar

Please send a certified copy of my birth certificate. As required, the fee of $30 is enclosed as part of the application, along with a stamped self-addressed envelope.

Name on certificate: William Hayes
Father's Name: Arthur Hayes
Mother's Maiden Name: Mary Brown
Date of Birth: March 8, 2009
Sex: Male
Place of Birth: Hometown Pennsylvania
Location: Community Hospital

Thank You.

Signature:
Printed Name: William Hayes
Address: 10000 Street Road, Hometown VA, 00000