Fillable Printable Affidavit for Correction of A Birth or Death Record
Fillable Printable Affidavit for Correction of A Birth or Death Record
Affidavit for Correction of A Birth or Death Record
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF VITAL RECORDS
AFFIDAVIT FOR CORRECTION OF A BIRTH OR DEATH RECORD
STATE FILE NUMBER
Indicate below the type of certificate to be amended or corrected. PRINT or TYPE the information identifying the certificate and the item to
be changed. This form must be signed in the presence of a Notary Public or the request cannot be processed and will be returned.
Please note:
1. Affidavits containing erasures, write-overs and/or white-out, faxed or reproduced copies of completed form will not be accepted.
2. An item which has been amended once by an affidavit cannot be amended again by an affidavit; it will require a Court Order.
Mail the completed form to: Missouri Department of Health and Senior Services
Bureau of Vital Records
P.O. Box 570
Jefferson City, MO 65102-0570
Before me appears _______________________________________ who, upon his/her oath, states that the original record of birth/death for
(PRESENT LEGAL NAME) (CIRCLE ONE) (CIRCLE ONE)
__________________________________________ born/died ________________________ in the State of Missouri.
(NAME AS SHOWN ON RECORD)
(CIRCLE ONE)
(MONTH/DAY/YEAR)
SHOULD BE CORRECTED AS FOLLOWS:
ITEM NO./ITEM NAME SHOULD READ
INSTEAD OF
ITEM NO./ITEM NAME SHOULD READ
INSTEAD OF
Y
ITEM NO./ITEM NAME SHOULD READ
ONLUSE
INSTEAD OF
TE
ITEM NO./ITEM NAME SHOULD READ
ASTFOR
INSTEAD OF
ITEM NO./ITEM NAME SHOULD READ
INSTEAD OF
ITEM NO./ITEM NAME SHOULD READ
INSTEAD OF
THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
AFFIANT SIGNATURE (MUST BE SIGNED IN PRESENCE OF NOTARY) RELATIONSHIP
PRESENT ADDRESS (STREET, AND/OR P.O. BOX, CITY, STATE, ZIP)
NOTARY PUBLIC EMBOSSER SEAL STATE COUNTY
SUBSCRIBED AND SWORN BEFORE ME, THIS USE RUBBER STAMP IN CLEAR AREA BELOW
DAY OF 20
NOTARY PUBLIC SIGNATURE MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 580-0645 (4-13) VS-460
