Fillable Printable Application for Certified Marriage Certificate - Virginia

Application for Certified Marriage Certificate - Virginia

CITY

PLACE OF APPLICATION

BRIDE’S MAIDEN NAME

(FIRST-MIDDLE-LAST)

GROOM’S NAME

(FIRST-MIDDLE-LAST)

DATE OF MARRIAGE

COUNTY STATE

Application for Certified Marriage Certificate

Vital Registration Office

Room 165

350 Capitol Street

Charleston WV, 2530

1-3701

(

304) 558-2931

www.wvdhhr.org

AMOUNT

MONEY ORDER

WHEN STAMPED PAID

THIS IS YOUR RECEIPT

For Office Use Only

CASH

CHECK

NO. COPIES

MONTH/DAY/YEAR

City, State, Zip

Mail Certificate to

Mailing Address

Suite or Apar tment Number

What is Your Relationship to the Bride or the Groom ?

I understand that intentionally making a false statement on this application or obtaining,

possessing, or using a vital r ecord other than is allowed by law or using the vital record of

another with an intent to deceive is a

FELONY under the law of the State of West Virginia

(WV Code §16-5-38).

Signat ure Required

Note: A $12.00 nonrefundable search fee

must accompany this application. This fee

includes on e copy, if found. Each additional

copy is $12 . Cas his sent at sen der’s risk .

Make check or money order payable to

“VITAL REGISTRATION”