Town of Ashby
Massachusetts

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REQUEST FOR VITAL RECORD
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Mail to: Town Clerk, 895 Main St, Ashby, MA 01431

In order to request a birth, death, or marriage certificate, please fill in the appropriate section below; send this form, together with a check for $5.00 for each certificate requested to the address above. Fill in your name and address at the bottom of this sheet. If the record is restricted (parents were not married at time of birth, father not named, or in a marriage if any parents were not married at the time of the bride or groom’s birth); please send a photocopy of your driver’s license; since only those named on the certificate have a right to said document.

Please mail the following to me at:

Name:________________________________________________________

Address:______________________________________________________

City/State/Zip:_________________________________________________

I WISH TO REQUEST A BIRTH CERTIFICATE FOR:___________________________________________, (Name of Child)

WHO WAS BORN IN THE TOWN OF ASHBY ON:_______________________________. (Date)

NAME OF FATHER (IF KNOWN):________________________________________

NAME OF MOTHER (IF KNOWN):_______________________________________

I WOULD LIKE ________________COPY/COPIES OF SAID DOCUMENT.

I WISH TO REQUEST A DEATH CERTIFICATE FOR:__________________________________________(Name of Decedent)

WHO DIED IN THE TOWN OF ASHBY ON:_____________________________________(Date of Death)

NAME OF FATHER (IF KNOWN)________________________________________

NAME OF MOTHER (IF KNOWN)_______________________________________

I WOULD LIKE _________________COPY/COPIES OF SAID DOCUMENT.

I WISH TO REQUEST A MARRIAGE CERTIFICATE FOR_____________________________________(Groom’s Name)

and ___________________________________ (Bride’s Name)

who were married on:______________________________(Date of Marriage)

I WOULD LIKE_________________COPY/COPIES OF SAID DOCUMENT

NOTE: Marriages are recorded where the bride and groom applied for their license NOT where they got married.