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Commonwealth Of
Virginia |
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Application For Certification of a
Vital Record |
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| 'Virginia statutes require a fee of
$8.00 be charged for each certification of a vital record or for a search of
the files when no certification |
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| is made. Please make check or money
order payable to State Health Department There is a $15.00 service charge for
returned checks. |
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| BIRTH |
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| Number |
Name
at Birth:
_______________________________________________________________________________ |
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| of Copies: |
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If
name has changed since birth due to adoption, court order, or any reason |
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| Paper:
_________ |
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other than
marriage please list changed name here: |
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| Plastic Card: ______ |
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| (NOTE: Plastic Card is not |
Date of Birth: |
____________________________ |
Race
_________________ Sex ____________ |
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| accepted by some agencies.) |
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Place of Birth: |
_________________________________________ |
_____________________ |
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Hospital of Birth
_________________________ |
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(City/County
in Virginia) |
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| Full Maiden Name of Mother: |
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| FullName
of Father: |
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| DEATH |
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| Number |
Name of Deceased: |
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| of
Copies: _______ |
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Date
of Death: ______________________ Age at Death ________________ Race
_________ Sex _____________ |
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Age at Death |
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Race _______ |
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Sex _____ |
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Place of
Death: _______________________________________ |
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Hospital Name
_____________________________________ |
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(City/County in Virginia) |
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| MARRIAGE |
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| Number |
Full
Name of Husband:
_________________________________________________________________________ |
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| of
Copies: ________ |
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Full
Name of Wife:
____________________________________________________________________________ |
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| DIVORCE |
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| Number |
Marriage - Date:
___________________________ |
Place:
_____________________________________________ |
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| of
Copies: _________ |
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Divorce - Date:
____________________________ |
Place:
_____________________________________________ |
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(City/County In Virginia) |
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| If
Marriage, place where license was issued:
__________________________________________________________________________________ |
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| Name
of Requester: __________________________________________ |
Daytime
Phone Number. ( )
_______________________ |
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| What
is your relationship to the person named on the certificate?
_________________________________________________________________ |
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| If
you are not the person named on the certificate, please state your direct and
tangible interest in receiving this oertificate: |
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| I
understand that making a false application for a Vital Record is a FELONY
under state and federal law. |
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| Signature
of Applicant:
____________________________________________________________________________________________________ |
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| Please
Indicate the address you wish the certificate(s) mailed to |
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| in the box below/
-- Please type or print clearly. |
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| Name |
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Send Completed
Application To: |
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| Address |
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Division of Vital Records |
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PO
Box 1000 |
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| City/State/Zip |
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Richmond, VA 23208-1000 |
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