The MarylandCommemorativeBirth CertificateCelebrate the joy of a new birthor the life of a loved one!The Maryland Department of Health

and Mental HygieneCenter for Maternal and Child Health

201 West Preston Street, Room 309Baltimore, Maryland 21201

1-877-4MD-DHMH (463-3464)Fax 410-333-5233

Maryland Relay 1-800-735-2258

Martin O’Malley, GovernorAnthony G. Brown, Lt. Governor

Joshua M. Sharfstein, M.D., Secretary

The services and facilities of the Maryland Departmentof Health and Mental Hygiene (DHMH) are operatedon a non-discriminatory basis. This policy prohibitsdiscrimination on the basis of race, color, sex, ornational origin and applies to the provisions ofemployment and granting of advantages, privileges,and accommodations.

The Department, in compliance with the AmericansWith Disabilities Act, ensures that qualified individualswith disabilities are given an opportunity to participatein and benefit from DHMH services, programs,benefits, and employment opportunities.

The Commemorative Birth CertificateProgram is administered bythe Division of Vital Records,Maryland Departmentof Health and Mental Hygiene6550 Reisterstown RoadBaltimore, Maryland 21215410-764-3038Toll Free 1-800-832-3277

Actual size: 11 X 14”This is an officiallegal document.

For more informationcall 410-764-3038

or Toll Free 1-800-832-3277.

The Commemorative BirthCertificate is a specially designed legalbirth certificate available to anyone bornin Maryland. This is a unique keepsaketo celebrate the birth of a new child, or tobe given as a special gift to a friend orrelative born in Maryland.

The Commemorative Birth Certificatefeatures:

• A design that includes the state flower,the Black-eyed Susan

• Handwritten calligraphy• A generous 11 x 14” size, on heirloom

quality paper suitable for framing• An official embossed seal of the State

of Maryland• A quotation from a Maryland poet,

Sister Maura Eichner• The signature of Maryland’s Governor,

Martin O’Malley

Purchase of a CommemorativeBirth Certificate alsohelps children in Maryland

Proceeds from the purchase of aCommemorative Birth Certificate will bedeposited into the Children’s Trust Fund.Administered by the Maryland Departmentof Health and Mental Hygiene’s Center forMaternal and Child Health, the Trust Fundprovides grants for programs and activitiesfor education, prevention and treatment ofchild abuse and neglect.

The cost of a Commemorative BirthCertificate is $30.00, $15 of which isdonated to the Children’s Trust Fund,and is fully tax deductible.

To purchase a certificate, please completethe application on the right, and sendit to:

Department of Health andMental HygieneDivision of Vital Records6550 Reisterstown RoadBaltimore, Maryland 21215

State regulations require that theCommemorative Birth Certificate onlybe issued to the person named on therecord, or a parent, legal guardian, orauthorized representative (having anotarized letter of authorization fromthe person on the record, parents, orlegal guardian).

The Commemorative Birth certificate willbe mailed directly to the person namedon the Certificate, or the eligible buyer(those individuals listed above).

For more information about theMaryland Children’s Trust Fund or theCommemorative Birth CertificateProgram, visit the Center for Maternaland Child Health’s Web site atwww.fha.state.md.us/mch.

Send a check or money order payable to The Divisionof Vital Records to: DHMH, Division of Vital Records,6550 Reisterstown Road, Baltimore, Maryland 21215.

PLEASE PRINT Date _______________

Name of record _____________________________________First, middle, last

Date of birth _____________________ Sex _____________Month/day/year

Place of birth _______________________________________City and county

Father’s full name __________________________________First, middle, last

Mother’s full name _________________________________First, middle, last

Your relationship to the personlisted on name of record ______________________________

NOTE: A non-refundable fee of $30.00 is required for eachcertificate requested. If the search provides no record,$18.00 will be refunded, and a Certificate of No Record willbe issued. A $12.00 search fee must be retained as required byMaryland law. You may apply in person or by mail. Youmust present a valid, unexpired, government-issued photo IDdisplaying a date issued and an expiration date. Applicantsunable to supply valid photo ID must present two differentpieces of alternative documentation. Acceptable documentsare a pay stub, current car registration, bank statement, letterfrom a government agency, lease/rental agreement, utility billwith current address, or a copy of your income tax return orW-2 form. At least one of these documents must contain yourcurrent mailing address. Requests will be mailed to theaddress displayed on the documents provided. Do not sendCASH or STAMPS.

Number of certified copies requested: ________________

Applicant’s name: ___________________________________Please print

Applicants signature ________________________________

Mailing address: ___________________________________City, State, ZIP code

Telephone number___________________________________