Request for Copy of
Genealogy Record

Government of Manitoba

Mailing Address
Please print your name and address clearly. This portion will be used when mailing your certificate

Name
Address Apt. No.
 
City Province Postal Code
Tel. No. - Business Tel. No. - Home

Payment Fees
$12.00 x ___ # of Records =

$_______ Total Fees Submitted

Please note, RUSH service is not available when requesting copies of Genealogy Records
1. Cash or Debit Card(in person only) or
2. Enclosed is a cheque/money order for $ _____ payable to the Minister of Finance or
3. Enclosed is a/are gift certificate(s) for $ _____ or
4. Credit Card       MasterCard       Visa
Card/Number      
Expiry Date: _________________________________________________________
Name on Card (please print) ____________________________________________
Signature of Cardholder:

Vital Statistics Agency
254 Portage Avenue
Winnipeg MB  R3C 0B6
Canada
Inquiries: Telephone
Toll-Free
Fax
E-Mail
204-945-3701
1-866-949-9296
204-948-3128
vitalstats@gov.mb.ca
File Number: