Birth Certificate

Please print out this form and return to:

Town Clerk’s Office

60 Center Square

East Longmeadow, MA 01028-2457

Requests submitted through the mail, will be processed on the date they are received.

Full name of person on the record of birth

First Middle Last

Date of birth

Month Day Year

Full Maiden Name of the Mother

First Middle Last

Full name of the Father

First Middle Last

Signature of Requester

Daytime telephone number

Area Code Number

Return Mailing Address

v Payment may be made in money order or certified bank check.

v Personal account checks are not accepted.

v Certified copies cost $10.00; please enclose a self addressed stamped envelope for each transaction through the mail.

v Make money order or certified bank check payable to “Town of East Longmeadow”

v NOTE: Some records are restricted or impounded and access may be denied. Please enclose a copy of your driver’s license.