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 show identification when requesting certified copies of a vital record at the state health department. Mail-in requests

must be notarized by an acceptable notary public.

Missouri law requires a non-refundable search fee for each five-year search of the files. If eligibility requirements are met and a record

is found, applicant is entitled to 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 FEMALE MALE

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 FEMALE MALE

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 STREET ADDRESS ___________________________________________________________________________

APPLICANT’S CITY/TOWN ________________________________ _

STATE _____________

ZIP _________________

PURPOSE FOR CERTIFICATE REQUEST _____________________________________________________________________

YOUR RELATIONSHIP TO PERSON NAMED ON RECORD (IF LEGAL GUARDIAN, 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 THAT I 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)