"Application for Certified Copy of West Virginia Birth Certificate" - West Virginia

Application for Certified Copy of West Virginia Birth Certificate is a legal document that was released by the West Virginia Department of Health and Human Resources - a government authority operating within West Virginia.

Form Details:

  • Released on January 9, 2009;
  • The latest edition currently provided by the West Virginia Department of Health and Human Resources;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the West Virginia Department of Health and Human Resources.

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Download "Application for Certified Copy of West Virginia Birth Certificate" - West Virginia

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Application for Certified Copy of West Virginia Birth Certificate
Please complete on-line, print, sign, and mail as instructed below or print except where signature is required.
The following pertains to information that would be found on the certificate being requested.
Name of person on the certificate
Date of Birth
Month/Day/Year
First
Middle
Last
Mother’s Maiden Name
Sex:
First
Middle
Last
Father’s Name
Male
Female
First
Middle
Last
Place of Birth
County
City
State
Hospital
Requestor’s Relationship:
Guardian or agent
Parent/Grandparent
Child/Grandchild
Brother/Sister
Spouse
Certificate of my own birth
Making false statements and misuse of vital records will result in criminal
and civil penalties pursuant to WV Code §16-5-38.
Printed Name (Required)
Signature (Required)
Requesting _____ copies at $12.00 per copy and enclosing $______________.
Please send check or money order. Please do not send cash.
Make checks payable to: Vital Registration
Send copies to:
Print
your address below.
(
)
Your daytime telephone number:
Area Code
E-Mail address
City
State
Zip
Submit form with check or money order to:
Vital Registration
Room 165
350 Capitol Street
Charleston, WV 25301-3701
Telephone: (304) 558-2931
Last Revised 1/9/09
Application for Certified Copy of West Virginia Birth Certificate
Please complete on-line, print, sign, and mail as instructed below or print except where signature is required.
The following pertains to information that would be found on the certificate being requested.
Name of person on the certificate
Date of Birth
Month/Day/Year
First
Middle
Last
Mother’s Maiden Name
Sex:
First
Middle
Last
Father’s Name
Male
Female
First
Middle
Last
Place of Birth
County
City
State
Hospital
Requestor’s Relationship:
Guardian or agent
Parent/Grandparent
Child/Grandchild
Brother/Sister
Spouse
Certificate of my own birth
Making false statements and misuse of vital records will result in criminal
and civil penalties pursuant to WV Code §16-5-38.
Printed Name (Required)
Signature (Required)
Requesting _____ copies at $12.00 per copy and enclosing $______________.
Please send check or money order. Please do not send cash.
Make checks payable to: Vital Registration
Send copies to:
Print
your address below.
(
)
Your daytime telephone number:
Area Code
E-Mail address
City
State
Zip
Submit form with check or money order to:
Vital Registration
Room 165
350 Capitol Street
Charleston, WV 25301-3701
Telephone: (304) 558-2931
Last Revised 1/9/09