West Virginia Death Certificate Request Form

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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):

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	    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