Application For Certification Of A Vital Record Form - Berkeley County Clerk
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2Berkeley County, West Virginia
Application for Certification of a Vital Record
The fee for each certification of a vital record is $5.00. Please make check or money order payable to
Berkeley County Clerk.
Name of Requester: _______________________________________Daytime Phone Number: (_____) _______________________
(person requesting the certificate)
Address:_____________________________________ City:___________________________ State: __________ Zip:__________
What is your relationship to the person named on the certificate? (Check one)
Self
Mother
Father
Child
Current Spouse
Sister
Brother
Maternal Grandparent
Paternal Grandparent
Legal Guardian (submit custody order)
Other (Specify) _______________________________________________________________________________________
What is your reason for requesting this certificate? ________________________________________________________________
I understand that making FALSE statements and MISUSE of vital records will result in criminal and civil penalties pursuant to West
Virginia Code 16-5-38. WV Code 16-5-38
Signature of Requester: ___________________________________________________ Date: ___________________________
BIRTH
Number
Name at Birth: _____________________________________________________________
of Copies _____ NOTE: If name has changed since birth due to adoption, court order or any reason other than marriage, please
list changed name here: ____________________________________________________________________
Date of Birth: ________________________________________________ Sex: _________________________
Place of Birth: _______________________________ Hospital of Birth: ________________________________
(City/County in West Virginia)
Full Maiden Name of Mother : _________________________________________________________________
Full Name of Father: _________________________________________________________________________
DEATH
Number
Name of Deceased: _____________________________________________________________
of Copies _____ Date of Death: _____________________________ Sex: _________________________
Place of Death: _______________________________ Hospital Name: ________________________________
(City/County in West Virginia)
Full Maiden Name of Mother : _________________________________________________________________
Full Name of Father: _________________________________________________________________________
MARRIAGE
Number
Full Name of Groom: ________________________________________________________________________
of Copies _____ Full Name of Bride: ___________________________________ ______________________________________
Marriage Date: ____________________ Place of Marriage: _________________________________________
Place where license was issued: _______________________________________________________________
Please indicate the address you wish the certificate(s) mailed to in the box below:. Please print or type clearly.
Send Completed Application to:
Name
Berkeley County Clerk
Address
Attention: Vital Statistics
100 West King Street
Martinsburg, WV 25401
Office: (304) 264 - 1927
City/State/Zip
Fax: (304) 267 - 1794
Email:
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