Form Adph-Hs14 - Vital Event Which Occurred In Alabama 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 a Certificate of Failure

to Find. For additional copies of the same record ordered at the same time, the fee is $6.00 each. 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.” Do not send cash. Fees are non-refundable. Do not request two different types of certificates on the same form.

PRINT ALL INFORMATION LEGIBLY. 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 expediting a request or ordering online, visit our website at

or call 334-206-5418

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. Valid identification must be submitted with a request for a restricted record. 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 receive certificate(s)

BIRTH:

_______________

_________________

(SEE ID REQUIREMENTS ON REVERSE SIDE)

NUMBER OF COPIES

AMOUNT PAID

FULL NAME AS ON

___________________________________________________________________________________________________

BIRTH CERTIFICATE

FIRST

MIDDLE

LAST

_____________________________________________________________________

______________________

DATE OF BIRTH

SEX

_____________________________________________

________________________________________________

COUNTY OF BIRTH

HOSPITAL

FULL NAME OF MOTHER/PARENT

__________________________________________________________________________________________

BEFORE FIRST MARRIAGE

FIRST

MIDDLE

LAST

FULL NAME OF FATHER/PARENT

__________________________________________________________________________________________

BEFORE FIRST MARRIAGE

FIRST

MIDDLE

LAST

DEATH:

_______________

_________________

(SEE ID REQUIREMENTS ON REVERSE SIDE)

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

___ MARRIAGE OR ___ DIVORCE:

_______________

_________________

NUMBER OF COPIES

AMOUNT PAID

FULL NAME OF SPOUSE 1

______________________________________________________________________________________________

BEFORE FIRST MARRIAGE

FIRST

MIDDLE

LAST

FULL NAME OF SPOUSE 2

______________________________________________________________________________________________

BEFORE FIRST MARRIAGE

FIRST

MIDDLE

LAST

___________________________

________________________________

IF MARRIAGE, DATE OF MARRIAGE

COUNTY WHERE LICENSE WAS ISSUED

_____________________________

____________________________________________

IF DIVORCE, DATE OF 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

ADPH-HS14/Rev. 1/2018

Informational materials in alternative formats will be made available upon request.

Form Adph-Hs14 - Vital Event Which Occurred In Alabama

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