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Application for Copy of Death Certificate

Name of person
on the certificate:
  Date of Death:  
  First Middle Last   Month/Day/Year

City:   County:   State  

Sex: (check one)   
   Male  Female  Unknown
Requestor's Relationship to the decedent: (check one)   
   Parent  Guardian or agent  Spouse  Child of decedent
   Other (describe):  

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

Signature   Printed Name
_______ copies at $12.00 per copy Enclosed is $___________. Please send check or money order. Please do not send cash.
Return copies to (Requestors address):



City State Zip Daytime telephone number ( ) ____________ Area Code
Return the form to:   Vital Registration Office
                      Room 165, 350 Capitol Street
                      Charleston, WV  25301-3701
                      Telephone: (304) 558-2931
 Make checks payable to: Vital Registration               Revised 01/9/09