Fillable Printable Application for Certified Marriage Certificate - West Virginia

Application for Certified Marriage Certificate - West 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, 25307-3701

(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 Apartment 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 record 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).

Signature Required

Note: A $12.00 nonrefundable search fee

must accompany this application. This fee

includes one copy, if found. Each additional

copy is $12 . Cashis sent at sender’s risk.

Make check or money order payable to

“VITAL REGISTRATION”