MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF VITAL RECORDS
APPLICATION FOR NON-CERTIFIED COPY OF AN
ORIGINAL BIRTH CERTIFICATE
BY ADOPTEE, ADOPTEE’S ATTORNEY OR BIRTH PARENT
P.O. Box 570
Jefferson City, Missouri 65102-0570
Telephone:(573) 751-6378
The adoptee, adoptee’s attorney, or the birth parent may request a copy of the adoptee’s original (prior to adoption) birth certificate. If you
are a lineal descendant, please complete "Application for Original Birth Certificate by Lineal Descendant". Birth parent's name must be listed
on the certificate in order for the certificate to be released. Applicants may mail the required application with payment or submit it in our
office in Jefferson City. A copy of an original birth certificate for adoptees born in Missouri cannot be ordered online.
The following information is needed in order to find and match your application with Bureau of Vital Records files. Please provide as much
accurate information as you can to avoid delays and increase the likelihood of being able to process this application. Missouri Department
of Health and Senior Services is unable to search by birth parent name. The Bureau of Vital Records will notify you if no record is
found.
Contact Preference and Medical History Forms may be released to the adoptee, adoptee's attorney, or birth parent if completed forms have
been submitted. Information may be redacted on the original (prior to adoption) birth certificate dependent on if or how a birth parent
completed a Birth Parent Contact Preference Form.
A NON-REFUNDABLE SEARCH FEE OF $15 MUST ACCOMPANY THIS APPLICATION. Make check or money order payable to:
Missouri Department of Health and Senior Services. Mail to: Bureau of Vital Records, P.O. Box 570, Jefferson City, MO65102-0570.
Please print clearly and complete as many of the items below as possible.
FULL NAME OF CHILD ON ORIGINAL BIRTH CERTIFICATE (IF KNOWN)
DATE OF BIRTH CHILD’S SEX MISSOURI CITY AND COUNTY WHERE BORN
BIRTH MOTHER/PARENT NAME (FIRST, MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE) (IF KNOWN) BIRTH MOTHER/PARENT NAME (FIRST, MIDDLE, CURRENT LEGAL LAST NAME) (IF KNOWN)
BIRTH FATHER/PARENT NAME (FIRST, MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE) (IF KNOWN) ANY OTHER INFORMATION THAT MAY HELP IDENTIFY THE RECORD (E.G., PARTIAL NAME, MOTHER’S AGE, NAME
OF ADOPTION AGENCY, ETC.)
TE KNOWN)
FULL NAME OF CHILD AFTER ADOPTION
DA OF ADOPTION (IF PLACE OF ADOPTION (IF KNOWN)
ADOPTIVE MOTHER/PARENT NAME (FIRST, MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE)
ADOPTIVE FATHER/PARENT NAME (FIRST, MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE)
APPLICANT’S NAME RELATIONSHIP TO ADOPTEE
Self Attorney for Adoptee Birth Parent
MAILING ADDRESS CITY STATE ZIP CODE
APPLICANT’S TELEPHONE NUMBER
I _________________________________________________, subject to the penalty of perjury, do solemnly declare and affirm that I am eligible to receive a non-certified
copy of the original birth certificate requested above and that the information contained in this application is true and correct to the best of my knowledge. I attest that I
am the adoptee, adoptee's attorney, or birth parent.
SIGNATURE OF APPLICANT DATE
NOTARY PUBLIC EMBOSSER SEAL STATE COUNTY
SUBSCRIBED AND SWORN BEFORE ME, THIS
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 580-3139 (
8-18)
VS-902
DAY OF
