Internet form 01/09/09
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Application for Copy of Birth Certificate
Name of person on the certificate: ______________________________________________
First Middle Last
Date of Birth ________________
Month/Day/Year
Mother's Maiden Name ______________________________________________
First Middle Last
Father's Name ______________________________________________
First Middle Last
Place of Birth
City _____________________County ____________________ State ________________
Hospital _____________________ Sex ____ Male; ___ Female;
Requestor's Relationship:____Parent/Grandparent;____ Guardian or Agent;
_____Brother/Sister ____ Child/Grandchild; ____ Certificate of my own birth; _____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
LAST REVISED 1/9/09