Massachusetts Application for a Non-Certified Record of Birth Prior to Adoption (R-109)

Who can use this form

• An adult adoptee (18 or older) who was born in Massachusetts.
• An adult child (18 or older) of a deceased parent who was an adoptee born in Massachusetts.
• The parent or legal guardian of a child under 18 whose deceased parent was an adoptee born in Massachusetts.
• The adoptive parent of a child under 18 born in Massachusetts.
• The registry's records date back to 1936. Earlier records are at the Massachusetts State Archives.

What to send with it

• The completed application. By mail, the affidavit section must be signed and dated in front of a notary.
• A clear photocopy of a valid, non-expired driver's license, motor vehicle department ID card or passport.
• If the name on the ID differs from the name at adoption: an original certified copy of a marriage certificate or legal name change decree.
• For a deceased parent's record: original certified copies of the parent's death record and of the applicant's own birth record.
• A check or money order payable to the Commonwealth of Massachusetts. Do not send cash by mail. Cards are not accepted.
• Original documents are returned with the completed order. The record is sent by certified mail.

Where to send it

Mail to

Registry of Vital Records and Statistics (RVRS) 150 Mount Vernon Street, 1st Floor Dorchester, MA 02125

State fee

$32 per copy by mail; $20 per copy in person. No refund if the certified mail is not signed for and the record is returned.

Typical processing

Not provided

Form revision

02/2026

Source

Official government page