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                      Commonwealth Of Virginia
     Application For Certification of a Vital Record
    '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
    is made. Please make check or money order payable to State Health Department There is a $15.00 service charge for returned checks.
Number Name at Birth: _______________________________________________________________________________
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:  
          Plastic Card: ______  
(NOTE: Plastic Card is not Date of Birth: ____________________________ Race _________________    Sex ____________
accepted by some agencies.)  
  Place of Birth:  _________________________________________ _____________________ Hospital of Birth _________________________
                                  (City/County in Virginia)     
Full Maiden Name of Mother:                
FullName of Father:                
Number Name of Deceased:  
of Copies: _______  
  Date of Death: ______________________  Age at Death ________________ Race _________ Sex _____________     Age at Death    Race _______   Sex _____
  Place of Death: _______________________________________   Hospital Name _____________________________________  
                       (City/County in Virginia)        
Number Full Name of Husband: _________________________________________________________________________  
of Copies:   ________  
  Full Name of Wife: ____________________________________________________________________________  
Number Marriage - Date: ___________________________ Place: _____________________________________________  
of Copies: _________  
  Divorce - Date: ____________________________ Place: _____________________________________________  
                                      (City/County In Virginia)
If Marriage, place where license was issued: __________________________________________________________________________________  
Name of Requester: __________________________________________ Daytime Phone Number. (          ) _______________________  
What is your relationship to the person named on the certificate? _________________________________________________________________  
If you are not the person named on the certificate, please state your direct and tangible interest in receiving this oertificate:
I understand that making a false application for a Vital Record is a FELONY under state and federal law.
Signature of Applicant: ____________________________________________________________________________________________________  
Please Indicate the address you wish the certificate(s) mailed to
in the box below/ -- Please type or print clearly.
Name       Send Completed Application To:
Address     Division of Vital Records
        PO Box 1000
City/State/Zip   Richmond, VA 23208-1000