Vital Records Request Form printable pdf download

USE ONLY FOR A VITAL EVENT WHICH OCCURRED IN ALABAMA

The fee for a birth, death, marriage or divorce record search is $15.00, which includes the cost of one certified copy OR Certificate of Failure to

Find. For additional copies of the same record ordered at the same time, the fee is $6.00 each. For information on how to expedite a document,

call 334-206-5418. Amendments, adoptions, legitimations, and delayed certificates must be processed through the Center for Health Statistics.

The fee is $20.00 to amend a record or file a delayed certificate which also covers the cost of one certified copy of the record. The fee is $25.00

to prepare a new certificate of birth after adoption or legitimation which also covers the cost of one certified copy of the record. Make check or

money order payable to the "State Board of Health." Fees are non-refundable. Do not request two different types of certificates on the same

PRINT ALL INFORMATION LEGIBLY

form.

. You must complete & sign the applicant section or your request cannot be processed.

TAKE THIS FORM TO YOUR LOCAL ALABAMA COUNTY HEALTH DEPARTMENT OR MAIL THIS FORM TO:

Alabama Department of Public Health, Center for Health Statistics, P.O. Box 5625, Montgomery, Alabama 36103-5625

For information on ordering a vital record via the Internet, visit our web site at: http: //

APPLICANT SECTION (THIS SECTION MUST BE COMPLETED) Birth certificates less than 125 years old and death certificates less than 25 years old are

restricted records.

You must be an immediate family member OR demonstrate a legal right to the record in order to obtain a copy of the record

(§ 22-9A-21).

Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up to $500. Code

of Ala. 1975, § 13A-10-109.

By signing, you are certifying you have a legal right to the record requested.

Your Signature________________________________________________________________________________Date________________________________________

Print Your Name

Address _____________________________________________________________

_________________________________________________________________________

City

State________ Zip__________________ Daytime Phone

_____________________________________________________

(____________)______________________________________________

Your Relationship to Person Whose Record is Being Requested _________________________________________________________________________________

Reason for Request (if not immediate family)___________________________________________________________________________________________________

I allow the following individual to pick up the certificate(s)________________________________________________________________________________________

BIRTH:

NUMBER OF COPIES _____________________

AMOUNT PAID $____________________________

FULL NAME AS ON

BIRTH CERTIFICATE______________________________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

DATE OF BIRTH __________________________________________________________________________SEX____________________________________________________________________

COUNTY OF BIRTH ____________________________________________________________________ HOSPITAL________________________________________________________________

FULL MAIDEN NAME OF MOTHER__________________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

FULL NAME OF FATHER___________________________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

DEATH:

NUMBER OF COPIES _____________________

AMOUNT PAID $____________________________

LEGAL NAME OF DECEASED______________________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

DATE OF DEATH ____________________________________ COUNTY OF DEATH ______________________________________________ SEX______________________________________

SSN ___________________________________________________ DATE OF BIRTH OR AGE ________________________________________ RACE___________________________________

NAME OF SPOUSE_______________________________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

NAME OF PARENTS________________________________________________________________________________________________________________________________

Indicate the number of copies of each type of certificate

STARTING WITH 1991 DEATHS, CERTIFICATES MAY BE ISSUED WITHOUT A CAUSE OF DEATH.

you

want:

WITH CAUSE OF DEATH

WITHOUT CAUSE OF DEATH

Q Q Q Q

MARRIAGE OR

DIVORCE:

NUMBER OF COPIES ______________________

AMOUNT PAID $______________________

FULL NAME OF HUSBAND____________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

FULL MAIDEN NAME OF WIFE_________________________________________________________________________________________________________________________

FIRST

MIDDLE

LAST

DATE OF MARRIAGE_______________________________________________ (OR) DATE OF DIVORCE____________________________________________________________

IF MARRIAGE, COUNTY WHERE LICENSE WAS ISSUED_____________________________________________________________________________________________________________

IF DIVORCE, COUNTY OF DIVORCE________________________________________________________________________________________________________________________________

COUNTY REGISTRAR USE: This application has been reviewed for the individual's right to receive the requested document(s).

__________

_____________________________________________________________________

_________________________

_________________________________________________

County Registrar's Signature

Date

County Health Department Receipt Number

Informational materials in alternative formats will be made available upon request

ADPH-HS14/Rev. 10-01-2009