Application for Certified Copy of West Virginia Birth Certificate
Please complete on-line, print, sign, and mail as instructed below or print except where signature is required.
The following pertains to information that would be found on the certificate being requested.
Name of person on the certificate
Date of Birth
First Middle Last
Month/Day/Year
Mother’s Maiden Name
First Middle Last
Sex:
Father’s Name
First Middle Last
Place of Birth
County
City
State
Hospital
Male
Female
Requestor’s Relationship:
Guardian or agent
Parent/Grandparent
Child/Grandchild
Certificate of my own birth
Brother/Sister
Spouse
Making false statements and misuse of vital records will result in criminal
and civil penalties pursuant to WV Code §16-5-38.
Printed Name (Required)
Requesting _____ copies at $12.00 per copy and enclosing $______________.
Signature (Required)
Please send check or money order. Please do not send cash.
Make checks payable to: Vital Registration
Send copies to: Print
your address below.
( )
Area Code
Your daytime telephone number:
E-Mail address
City State Zip
Submit form with check or money order to:
Vital Registration
Room 165
350 Capitol Street
Charleston, WV 25301-3701
Telephone: (304) 558-2931
Last Revised 1/9/09
