Harrison County Application For Certified Copies Of Vital Records
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1HARRISON COUNTY APPLICATION FOR CERTIFIED COPIES OF
VITAL RECORDS
Susan J. Thomas , Clerk
Certificate Requested:
(What type of Certificate is being ordered)
Birth Certificate
Marriage Certificate
Death Certificate
What is your relationship to the person named on the certificate? (check one)
___ Self ___ Mother ___ Father ___ Child ___ Current Spouse ___ Sibling ___ Grandparent
___ Grandchild ___ Step Parent ___ Step Children ___ In Laws ___ Legal Guardian (submit custody
order) ___ Attorney ___ Other (Explain) _________________________________________________
Birth:
Name at Birth: ___________________________________________
$5.00 per copy
Date of Birth: ___________________________________________
Number of copies:
Mother’s Maiden Name: ___________________________________
_______
Father’s Name: __________________________________________
Laminated Birth:
$7.00 per copy
***The Laminated Certificates may not be an acceptable form of ID to obtain
(wallet size)
a passport and possibly other Documents.
Number of copies: _____
Marriage:
Full Name of Groom: ___________________________________________
$5.00 per copy
Full Maiden Name of Bride: _____________________________________
Number of copies:
Date of Marriage: ______________________________________________
_______
Death:
Name of the Deceased: ___________________________________________
$5.00 per copy
Date of Death: __________________________________________________
Number of copies:
_______
Applicant Information: (information about the person requesting the record)
Applicant Name: ____________________________ Email: __________________________________
Mailing Address: ____________________________ Phone #: ________________________________
City, State, & Zip: ___________________________
Signature of Applicant: ________________________________________________________________
***PLEASE ATTACH A COPY OF YOUR PHOTO ID***
Method of Payment: Check
Money Order
Credit Card
(please check one)
(please fill in credit card info below)
Please make checks payable to: Harrison County Clerk
* Notice: The following fees will apply to all credit card transactions & will be added to the total amount due:
0-$50 = $2.00 fee
$50.01 - $100.00 = $3.00 fee
Each additional $100 = $3.00
We accept MasterCard, Visa, Discover, American Express
Card Holder’s First Name:________________________
Card Number: ___________________________
Card Holder’s Last Name: ________________________
Expiration Date: _________________________
Card Holder’s Address: __________________________
CVN: (3 digit code on back) _______________
City, State, & Zip: ______________________________
Phone #: ______________________________________
Please mail payment to: Harrison County Clerks Office 301 W Main St, Clarksburg, WV 26301
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