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Authorization to Release a Vital Record Date: I, hereby authorize (name of person eligible for record) (name of person to obtain record) to obtain the following record: (check all that apply) birth – date of event death - date of event marriage – date of event of (name of person on record to be released) Signature of Person Eligible for Record Relationship to Person on Record Personally appeared before me this day of 20 at Maine, by to be his/her free (name of person acknowledged) act and deed. Signature of Notary/Attorney Printed Name of Notary/Attorney Date Commission Expires 7-13-2010