WV | DHHR | BPH | OEHP | HSC | VITAL
Internet form 01/9/2009
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Application for Copy of Marriage Certificate

Husband's Name: ______________________________________________
First           Middle         Last
Bride's Maiden Name: ______________________________________________
First           Middle           Last 
Date of Marriage ______________________
Month/Day/Year
Place of Marriage ____________________ ________________
CountyState
Requestor's Relationship

____ Guardian or Agent; ____ Child/Grandchild; ____ Certificate of my own Marriage; _____Spouse;

Making false statements and misuse of vital records will result in criminal and civil penalties pursuant to WV Code §16-5-38).



__________________________ ____________________________ Signature Printed Name
Requesting ________ copies at $12.00 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.
______________________________________________

______________________________________________

______________________________________________

______________________________________________
City State Zip Daytime telephone number ( ) ______ ___________ Area Code


Separate on the above line and return the form to:
	Vital Registration 
	Room 165
	350 Capitol Street
	Charleston, WV  25301-3701
	
	Telephone: (304) 558-2931
Make checks payable to: Vital Registration
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LAST REVISED 1/9/09