Fillable Printable Application for Certified Copy of Birth Certificate - West Virginia

Application for Certified Copy of Birth Certificate - West Virginia

Application for Certified Copy of West Virginia Birth Certificate

Please complete on-line, print, sign, and mail as instructed below or print except where signature is required.

The following pertains to information that would be found on the certificate being requested.

Name of person on the certificate

Date of Birth

First Middle Last

Month/Day/Year

Mother’s Maiden Name

First Middle Last

Sex:

Father’s Name

First Middle Last

Place of Birth

County

City

State

Hospital

Male

Female

Requestor’s Relationship:

Guardian or agent

Parent/Grandparent

Child/Grandchild

Certificate of my own birth

Brother/Sister

Spouse

Making false statements and misuse of vital records will result in criminal

and civil penalties pursuant to WV Code §16-5-38.

Printed Name (Required)

Requesting _____ copies at $12.00 per copy and enclosing $______________.

Signature (Required)

Please send check or money order. Please do not send cash.

Make checks payable to: Vital Registration

Send copies to: Print

your address below.

( )

Area Code

Your daytime telephone number:

E-Mail address

City State Zip

Submit form with check or money order to:

Vital Registration

Room 165

350 Capitol Street

Charleston, WV 25301-3701

Telephone: (304) 558-2931

Last Revised 1/9/09