Form Vs-37 - Application For Birth Certificate
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1COMMONWEALTH OF KENTUCKY
STATE REGISTRAR OF VITAL STATISTICS
VS-37
(Rev. 6/00)
APPLICATION FOR BIRTH CERTIFICATE
Please Print Or Type All Information Required On This Form
Name on Certificate _____________________________________________________
Sex ____________
Date of Birth _______________________ Kentucky County of Birth _______________________________
Mother’s Full Maiden Name ________________________________________________________________
Father’s Name ___________________________________________________________________________
Hospital ________________________________________________________________________________
______________________________________________
Phone: _____________________________
(Signature of Applicant)
(Area Code)
(Number)
Relationship To Person Named On Certificate __________________
Office Use Only
Vol __________________
A $10.00 fee must accompany this application.
Cert __________________
KRS 213.141 mandates that $3.00 of this fee be used toward the
Year __________________
prevention of child abuse and that $1.00 of this fee be used to provide
coverage for inherited metabolic disease products for uninsured children.
Date __________________
Initials ________________
The $10.00 fee cannot be returned if the certificate is not found. If the certificate is on file you will receive one
copy. Additional copies are $10.00 each. Make check or money order payable to “Kentucky State Treasurer”.
When complete, mail the entire form to: Vital Statistics, 275 East Main 1E-A, Frankfort, Kentucky 40621.
…………………………………………………………………………………………………………………...
Certified Copies - $10.00 Each Copy – Number of copies desired _________
Name and Mailing Address Required
If you have not received your certificate(s)
within 30 working days from the postmarked
date of mailing, please contact the Office of
_________________________________
VITAL STATISTICS at: 502-564-4212
_________________________________
Applicant’s Phone _______________________
_________________________________
(Area Code)
(Number)
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