Fillable Printable Application for Certification of a Vital Record - Virginia

Application for Certification of a Vital Record - Virginia

VS6-2/06

COMMONWEALTH OF VIRGINIA

Application for Certification of a Vital Record

Virginia statutes require a fee of $12.00 be charged for each certification of a vital record or for a search of the files when no certification is made.

Please make check or money order payable to State Health Department

. There is a $50.00 service charge for returned checks.

Name of Requester: ________________________________________________ Daytime Phone Number (______)

______-_____________________

(person requesting the certificate)

Address: ______________ _______________ _______________ ____ City: ___________________________ State: __________________ Zip: ___________________

What is your relationship to the person named on the certificate? (Check one)

Self Mother Father Child Current Spouse Sister Brother Maternal Grandparent

Paternal Grandparent Legal Guardian (submit custody order) Other (Specify) _________________________________

What is your reason for requesting this certificate? _____ ___ ___ ______ ___ ___ ___ __ ____ ______ ___ __ ____ ___ ___ _____ ____ ___ ___

I understand that making a FALSE application for a vital record is a FELONY under state and federal law.

Signature of Requester

: ___________________________________________________________________________

IMPORTANT

The person requesting the vital record must submit an enlarged, legible (readable) clear photo copy of their identification. See list below.

BIRTH CARDS ARE

NO LONGER AVAILABLE

BIRTH

Number Name at Birth:

of Copies If name has changed since birth due to adoption, court order, or any reason

Paper: ____________ other than marriage, please list changed name here:

_______ ______________________________________ ____________________________________

Date of Birth: Race: Sex:

Place of Birth: Hospital of Birth:

(City/County in Virginia)

Full Maiden Name of Mother:

Full Name of Father: _______________________________________________________________

DEATH STILLBIRTH

Number Name of Deceased: ________________________________________________________________

of Copies: ___________

Date of Death: Age at Death: Race: Sex: __________

Place of Death: Hospital Name: ______________________

(City/County in Virginia)

Full Maiden name of Mother: _______________ _______________ _______________ __________

Full Name of Father: _______________________________________________________________

MARRIAGE

Number Full Name of Husband:

of Copies: ____________

Full Name of Wife:

DIVORCE

Number Marriage - Date: Place:

of Copies: ____________

Divorce - Date: Place:

(City/County in Virginia)

If Marr iage, place where license was issued: _______________________________________ ______

Please indicate the address you wish the certificate( s) mailed to in the box below. -- Please type or print clearly.

Name Send Completed Application To:

Address Division of Vital Records

P. O. Box 1000

Richmond, VA 23218-1000

City/State/Zip

(804) 662-6200

www.vdh.virginia.gov

The State Registrar reserves the right (§32.1-271C) to accept or deny any application submitted.

ACCEPTABLE IDENTIFICATION

SUBMIT ONE (1) DOCUMENT FROM THE PRIMARY LIST OR TWO (2) DOCUMENTS FROM

THE SECONDARY LIST.

The acceptable documents listed may change without prior notice.

PRIMARY LIST

Photo Drivers License issued by US DMV office - unexpired or expired for not more than one year

Photo Learners/Instruction Permit issue by US DMV office -unexpired or expired for not more than one year

Photo Identification Card issued by US DMV Office - unexpired or expired for not more than one year

Current Photo Identification Card - (school, employment). Check Cashing Cards are not accepta ble

Military Card - unexpired - active duty or retired member

U.S. Passport – unexpired

Foreign Passport with Visa, I-94 or I-94W - unexpired

U.S. Certificate of Naturalization - (form N-550, N-570 or N-578)

U.S. Certificate of Citizenship - (form N-560 or N-561)

10.

U.S. Citizen Identification Card - (form I-197)

11.

Temporary Resident Card - unexpired - (form I-688)

12.

Employment Authorization Card - unexpired - (form I-688A, I-688B)

13.

Refugee Travel Document - unexpired- (form I-571)

14.

Resident Alien Card – unexpired - (form I-551)

15.

Permanent Resident Card - unexpired - (form I-551)

16.

Northern Marianas Card - unexpired - (form I-551)

17.

Asylum - A copy of the first and last page of application for Asylum

18.

Birth Abroad (Consular Report) of a Citizen of the U.S.A. (form FS-240)

19.

Birth Abroad (Certification of Report) of a Citizen of the U.S.A.

20. Virginia Criminal Justice Agency Offender Information Form

21. United States Probation Offender Information Form

SECONDARY LIST

22. U.S. Selective Service Card

23.

U.S. Military Discharge Papers - (form DD214)

24.

Certified School Records/Transcript issued by a U.S. state or territory

25.

Enrollment, Certificate of - issued by VA Dept of Education

26. Life insurance policy

27.

Health care insurance card

28.

Welfare/social services identification card with photo - unexpired – issued by municipality

29.

Photo Drivers License - issued by US DMV office expired not m ore than 5 years

30.

Photo Learners/Instruction Permit - issued by US DMV office expired not more than 5 years

31.

Photo Identification card - issued by US DMV office expired not more than 5 years

32.

U. S. Passport - expired not more than 5 years

33.

Foreign Passport - expired not more than 5 years, with a VISA,

34.

Military dependent ID card, with photo - unexpired

35.

Weapons or gun permit issued by federal state or municipal government-unexpired

36.

Pilots License – unexpired

37.

INS form I-797 (applicable only for individuals whose names appear on the form)

38.

IAP-66 U.S. Department of State form (applicable only for the individuals whose names appear on the form).

39. Veterans Universal Access Identification Card