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 a copy of their identification. See list on reverse side.
BIRTH CARDS ARE NO LONGER AVAILABLE.
BIRTH
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Name at Birth: |
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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: |
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_________________________________________________________________________________ |
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Date of Birth: |
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Race: |
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Sex: |
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Place of Birth: |
Hospital of Birth: |
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(City/County in Virginia) |
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Full Maiden Name of Mother: |
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Full Name of Father: _______________________________________________________________ |
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DEATH |
STILLBIRTH |
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Name of Deceased: ________________________________________________________________ |
of Copies: ___________ |
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Date of Death: |
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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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Full Maiden name of Mother: _______________________________________________________ |
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Full Name of Father: _______________________________________________________________ |
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MARRIAGE |
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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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Marriage - Date: |
Place: |
of Copies: ____________ |
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Divorce - Date: |
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Place: |
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(City/County in Virginia) |
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If Marriage, place where license was issued: _____________________________________________ |
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Please indicate the address you wish the certificate(s) mailed to in the box below. -- Please type or print clearly.
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Send Completed Application To: |
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Division of Vital Records |
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P. O. Box 1000 |
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Richmond, VA 23218-1000 |
City/State/Zip |
(804) 662-6200 |
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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
1.Photo Drivers License issued by US DMV office - unexpired or expired for not more than one year
2.Photo Learners/Instruction Permit issue by US DMV office -unexpired or expired for not more than one year
3.Photo Identification Card issued by US DMV Office - unexpired or expired for not more than one year
4.Current Photo Identification Card - (school, employment). Check Cashing Cards are not acceptable
5.Military Card - unexpired - active duty or retired member
6.U.S. Passport – unexpired
7. Foreign Passport with Visa, I-94 or I-94W - unexpired
8.U.S. Certificate of Naturalization - (form N-550, N-570 or N-578)
9.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
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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 more 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,