Form MO580-0641 "Application for a Vital Record" - Missouri

Form MO580-0641 or the "Application For A Vital Record" is a form issued by the Missouri Department of Health and Senior Services.

The form was last revised in May 1, 2012 and is available for digital filing. Download an up-to-date Form MO580-0641 in PDF-format down below or look it up on the Missouri Department of Health and Senior Services Forms website.

ADVERTISEMENT

Download Form MO580-0641 "Application for a Vital Record" - Missouri

1188 times
Rate
4.6(4.6 / 5) 71 votes
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
P.O. Box 570
BUREAU OF VITAL RECORDS
Jefferson City, Missouri 65102-0570
APPLICATION FOR A VITAL RECORD
Applicants must show identification when requesting certified copies of a vital record at the state health department. Mail-in requests
must be notarized by an acceptable notary public.
Missouri law requires a non-refundable search fee for each five-year search of the files. If eligibility requirements are met and a record
is found, applicant is entitled to certified copies. A statement will be issued if no record is found. FEE MUST ACCOMPANY
APPLICATION. FEES ARE VALID FOR ONE YEAR. Check or money order payable to: Missouri Department of Health and
Senior Services.
State recording of birth and death records began January 1, 1910.
NUMBER OF COPIES
_________ (FIRST COPY ISSUED $15;
BIRTH
FETAL DEATH REPORT
STILLBIRTH
EACH ADDITIONAL COPY $15)
FULL NAME ON CERTIFICATE ____________________________________________________________________________
ALSO KNOWN AS
___________________________________________
(INDICATE IF BIRTH COULD BE RECORDED UNDER ANOTHER NAME)
DATE OF BIRTH _____________
PLACE OF BIRTH
_______________________________________
(CITY, COUNTY, STATE)
HOSPITAL _______________________________________
SEX
RACE ___________________
FEMALE
MALE
FULL NAME OF FATHER
_________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER
________________________________________________________________________
NUMBER OF COPIES _______
(FIRST COPY ISSUED $13; EACH ADDITIONAL COPY OF
DEATH
THE SAME RECORD ORDERED AT THE SAME TIME $10)
FULL NAME ON CERTIFICATE ____________________________________________________________________________
DATE OF BIRTH _________________________________
SEX
RACE ___________________
FEMALE
MALE
DATE OF DEATH _______________ PLACE OF DEATH
_______________________________________
(CITY, COUNTY, STATE)
FULL NAME OF SPOUSE
_________________________________________________________________________________
FULL NAME OF FATHER
_________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER
________________________________________________________________________
PLEASE ENCLOSE A SELF ADDRESSED STAMPED ENVELOPE WITH YOUR REQUEST (PRINT THE FOLLOWING INFORMATION)
APPLICANT’S NAME ___________________________________________
PHONE NUMBER ______________________
APPLICANT’S STREET ADDRESS ___________________________________________________________________________
APPLICANT’S CITY/TOWN _________________________________
STATE _____________
ZIP _________________
PURPOSE FOR CERTIFICATE REQUEST _____________________________________________________________________
YOUR RELATIONSHIP TO PERSON NAMED ON RECORD
. IF LEGAL
(IF LEGAL GUARDIAN, MUST PROVIDE GUARDIANSHIP PAPERS)
REPRESENTATIVE, INDICATE LEGAL RELATIONSHIP. _______________________________________________________
 MAIL-IN REQUESTS MUST BE NOTARIZED. ALL APPLICATIONS MUST BE SIGNED.
I __________________________________ , SUBJECT TO THE PENALTY OF PERJURY, DO SOLEMNLY DECLARE AND
AFFIRM THAT I AM ELIGIBLE TO RECEIVE A CERTIFIED COPY OF THE VITAL RECORD(S) REQUESTED ABOVE AND THAT
THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
 APPLICANT’S SIGNATURE _____________________________________________ DATE ______________________
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY
SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME ,
USE RUBBER STAMP IN CLEAR AREA BELOW
THIS
_____________ DAY OF _________________ , 20 _____
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
WARNING: False application for a certified copy of a vital record is a crime.
MO 580-0641 (5-12)
VS-151BD
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
P.O. Box 570
BUREAU OF VITAL RECORDS
Jefferson City, Missouri 65102-0570
APPLICATION FOR A VITAL RECORD
Applicants must show identification when requesting certified copies of a vital record at the state health department. Mail-in requests
must be notarized by an acceptable notary public.
Missouri law requires a non-refundable search fee for each five-year search of the files. If eligibility requirements are met and a record
is found, applicant is entitled to certified copies. A statement will be issued if no record is found. FEE MUST ACCOMPANY
APPLICATION. FEES ARE VALID FOR ONE YEAR. Check or money order payable to: Missouri Department of Health and
Senior Services.
State recording of birth and death records began January 1, 1910.
NUMBER OF COPIES
_________ (FIRST COPY ISSUED $15;
BIRTH
FETAL DEATH REPORT
STILLBIRTH
EACH ADDITIONAL COPY $15)
FULL NAME ON CERTIFICATE ____________________________________________________________________________
ALSO KNOWN AS
___________________________________________
(INDICATE IF BIRTH COULD BE RECORDED UNDER ANOTHER NAME)
DATE OF BIRTH _____________
PLACE OF BIRTH
_______________________________________
(CITY, COUNTY, STATE)
HOSPITAL _______________________________________
SEX
RACE ___________________
FEMALE
MALE
FULL NAME OF FATHER
_________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER
________________________________________________________________________
NUMBER OF COPIES _______
(FIRST COPY ISSUED $13; EACH ADDITIONAL COPY OF
DEATH
THE SAME RECORD ORDERED AT THE SAME TIME $10)
FULL NAME ON CERTIFICATE ____________________________________________________________________________
DATE OF BIRTH _________________________________
SEX
RACE ___________________
FEMALE
MALE
DATE OF DEATH _______________ PLACE OF DEATH
_______________________________________
(CITY, COUNTY, STATE)
FULL NAME OF SPOUSE
_________________________________________________________________________________
FULL NAME OF FATHER
_________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER
________________________________________________________________________
PLEASE ENCLOSE A SELF ADDRESSED STAMPED ENVELOPE WITH YOUR REQUEST (PRINT THE FOLLOWING INFORMATION)
APPLICANT’S NAME ___________________________________________
PHONE NUMBER ______________________
APPLICANT’S STREET ADDRESS ___________________________________________________________________________
APPLICANT’S CITY/TOWN _________________________________
STATE _____________
ZIP _________________
PURPOSE FOR CERTIFICATE REQUEST _____________________________________________________________________
YOUR RELATIONSHIP TO PERSON NAMED ON RECORD
. IF LEGAL
(IF LEGAL GUARDIAN, MUST PROVIDE GUARDIANSHIP PAPERS)
REPRESENTATIVE, INDICATE LEGAL RELATIONSHIP. _______________________________________________________
 MAIL-IN REQUESTS MUST BE NOTARIZED. ALL APPLICATIONS MUST BE SIGNED.
I __________________________________ , SUBJECT TO THE PENALTY OF PERJURY, DO SOLEMNLY DECLARE AND
AFFIRM THAT I AM ELIGIBLE TO RECEIVE A CERTIFIED COPY OF THE VITAL RECORD(S) REQUESTED ABOVE AND THAT
THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
 APPLICANT’S SIGNATURE _____________________________________________ DATE ______________________
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY
SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME ,
USE RUBBER STAMP IN CLEAR AREA BELOW
THIS
_____________ DAY OF _________________ , 20 _____
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
WARNING: False application for a certified copy of a vital record is a crime.
MO 580-0641 (5-12)
VS-151BD
ADVERTISEMENT
Fill PDF online