Name of person on the certificate:
______________________________________________ Date
of Death ________________ First Middle Last Month/Day/Year City: _____________________County:
____________________ State: ________________ Hospital: _____________________ Sex:
____ Male; ___ Female; Requestor's Relationship:
____ Parent ____ Guardian or agent; ____ Grandparent; ____ Spouse; ____ Child
of decedent; ___Other (describe) ________________________________________________;
By my signature, I certify that the above marked relationship is true.
__________________________ ____________________________
Signature Printed Name
Reason for request: ____________________________________________________________________________
Enclosed is $___________ for _______ copies ($10.00 per copy).
Please send check or money order. Please do not send cash.
Return copies to (Requestors address):
______________________________________________
______________________________________________
______________________________________________
______________________________________________
City State Zip
Daytime telephone number ( ) ____________
Area Code
Separate on the above line and return the form to:
Vital Registration Program
Room 165
350 Capitol Street
Charleston, WV 25301-3701
Telephone: (304) 558-2931
Make checks payable to: Vital Registration