Application For Certified Copy Of West Virginia Birth Certificate
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1Application for Certified Copy of West Virginia Birth Certificate
Please complete on-line, print, sign, and mail as instructed below or print except where signature is required.
The following pertains to information that would be found on the certificate being requested.
Name of person on the certificate
Date of Birth
Month/Day/Year
First
Middle
Last
Mother’s Maiden Name
Sex:
First
Middle
Last
Male
Female
Father’s Name
First
Middle
Last
Place of Birth
County
City
State
Hospital
The information below pertains to the person requesting the certificate.
Requestor’s Relationship:
Guardian or agent
Child/Grandchild
Parent/Grandparent
Brother/Sister
Spouse
Certificate of my own birth
By my signature, I certify that the above marked relationship is true.
Printed Name (Required)
Signature (Required)
Requesting _____ copies at $5.00 ($10.00 after July 3, 2006) per copy and enclosing $______________.
Please send check or money order. Please do not send cash.
Make checks payable to: Vital Registration
Send copies to:
Print
your address below.
(
)
Your daytime telephone number:
Area Code
E-Mail address
City
State
Zip
Submit form with check or money order to:
Vital Registration
Room 165
350 Capitol Street
Charleston, WV 25301-3701
Telephone: (304) 558-2931
Last Revised 05/25/06
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