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 |
____________________ |
________________ |
| County | State |
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
LAST REVISED 1/9/09