Fillable Printable Application for a Vital Record - Missouri
Fillable Printable Application for a Vital Record - Missouri
Application for a Vital Record - Missouri
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
P.O. Box 570
BUREAU OF VITAL RECORDS
Jefferson City, Missouri 65102-0570
APPLICATION FOR A VITAL RECORD
WARNING: False application for a certified copy of a vital record is a crime.
MO 580-0641 (5-12) VS-151BD
Applicants must showidentification when requesting certified copies of a vital record atthe state health department. Mail-in requests
must be notarized by an acceptable notary public.
Missouri law requires anon-refundable search fee for each five-year search of the files. If eligibility requirements are met and a record
is found, applicant is entitledto certified copies. A statement will be issued if no record is found. FEE MUST ACCOMPANY
APPLICATION. FEES ARE VALID FOR ONE YEAR.Check or money order payable to: Missouri Department of Health and
Senior Services.
State recording of birth and death records began January 1, 1910.
BIRTH FETAL DEATH REPORT STILLBIRTH
NUMBER OF COPIES_________(FIRST COPY ISSUED $15;
EACH ADDITIONAL COPY $15)
FULL NAME ON CERTIFICATE____________________________________________________________________________
ALSO KNOWN AS (INDICATE IF BIRTH COULD BE RECORDED UNDER ANOTHER NAME)___________________________________________
DATE OF BIRTH _____________
PLACE OF BIRTH (CITY, COUNTY, STATE)_______________________________________
HOSPITAL _______________________________________
SEX FEMALEMALE
RACE ___________________
FULL NAME OF FATHER _________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER________________________________________________________________ ________
DEATH
NUMBER OF COPIES _______ (FIRST COPY ISSUED $13; EACH ADDITIONAL COPY OF
THE SAME RECORD ORDERED AT THE SAME TIME $10)
FULL NAME ON CERTIFICATE ____________________________________________________________________________
DATE OF BIRTH _________________________________
SEX FEMALEMALE
RACE ___________________
DATE OF DEATH _______________
PLACE OF DEATH (CITY, COUNTY, STATE)_______________________________________
FULL NAME OF SPOUSE _________________________________________________________________________________
FULL NAME OF FATHER _________________________________________________________________________________
FULL MAIDEN NAME OF MOTHER ________________________________________________________________ ________
PLEASE ENCLOSE A SELF ADDRESSED STAMPED ENVELOPE WITH YOUR REQUEST(PRINT THE FOLLOWING INFORMATION)
APPLICANT’S NAME___________________________________________
PHONE NUMBER ______________________
APPLICANT’S STREETADDRESS ___________________________________________________________________________
APPLICANT’S CITY/TOWN ________________________________ _
STATE _____________
ZIP _________________
PURPOSE FOR CERTIFICATE REQUEST_____________________________________________________________________
YOUR RELATIONSHIP TO PERSON NAMED ON RECORD (IF LEGALGUARDIAN, MUST PROVIDE GUARDIANSHIP PAPERS). IF LEGAL
REPRESENTATIVE, INDICATE LEGAL RELATIONSHIP._______________________________________________________
MAIL-IN REQUESTS MUST BE NOTARIZED. ALL APPLICATIONS MUST BE SIGNED.
I __________________________________, SUBJECT TO THE PENALTY OF PERJURY, DO SOLEMNLY DECLARE AND
AFFIRM THATI AM ELIGIBLE TO RECEIVE A CERTIFIED COPY OF THE VITAL RECORD(S) REQUESTED ABOVE AND THAT
THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
APPLICANT’S SIGNATURE _____________________________________________
DATE______________________
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY
SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME ,
USE RUBBER STAMP IN CLEAR AREA BELOW
THIS_____________DAY OF _________________ , 20 _____
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
