Fillable Dl82 VIRGINIA VITAL RECORD APPLICATION (Virginia Department of Motor Vehicles)

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Dl82 VIRGINIA VITAL RECORD APPLICATION (Virginia Department of Motor Vehicles)

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DL 82 (08-10-2019)
AGE AT DEATH
OR
CERTIFICATION/DOCUMENT REQUESTED
DEATH CERTIFICATE
NUMBER OF PAPER
COPIES REQUESTED
DECEASED NAME (print) - (first) (middle ) (last) (suffix)
YEARS:
DEATH LOCATION (Virginia city or county) HOSPITAL NAME (if appropriate)
check one: PRINT FULL NAME (first, middle, last, suffix)
MARRIAGE LOCATION (Virginia city or county)
PLACE WHERE LICENSE WAS ISSUED
DIVORCE LOCATION (Virginia city or county)
DATE OF DEATH (mm/dd/yyyy)
DIVORCE DATE (mm/dd/yyyy)
MARRIAGE DATE (mm/dd/yyyy)
DIVORCE CERTIFICATE
MARRIAGE CERTIFICATE
NUMBER OF PAPER
COPIES REQUESTED
SEX
FEMALEMALE
SEX
FEMALEMALE
SEX
FEMALEMALE
BRIDEGROOM
SPOUSE
MAIDEN NAME
check one: PRINT FULL NAME (first, middle, last, suffix)
BRIDEGROOM
SPOUSE
MAIDEN NAME
RACE OF DECEASED
LESS THAN
ONE YEAR
check one: PRINT FULL NAME (first, middle, last, suffix) MAIDEN NAME
MAIDEN NAME
FATHERPARENT
MOTHER
check one: PRINT FULL NAME (first, middle, last, suffix)
FATHERPARENT
MOTHER
SEX
FEMALEMALE
SEX
FEMALEMALE
TELEPHONE NUMBERREQUESTER EMAIL
SEX
FEMALEMALE
ZIP CODESTATE
CITY
REQUESTER ADDRESS
REQUESTER NAME (person requesting certification) (print) - (last) (first) (middle) (suffix)
REQUESTER/VITAL RECORD INFORMATION
RELATIONSHIP OF REQUESTER TO PERSON NAMED ON THE CERTIFICATE (check one)
SELF MOTHER FATHER CHILD SISTER BROTHER CURRENT SPOUSE
GRANDCHILD
(death certificate only)
GREAT GRANDCHILD
(death certificate only)
LEGAL REPRESENTATIVE
(Bar Card/Power of Attorney required)
EXECUTOR
(approved papers required)
NON RELATIVE (Public Record Request only)
NON IMMEDIATE FAMILY (Public Record Request only)
LEGAL GUARDIAN
(approved papers required)
FUNERAL DIRECTOR (death certificate only)
(enter license number)
REASON FOR REQUESTING
LIFE INSURANCE PURPOSES ESTATE SETTLEMENTS
TO CLOSE AN ACCOUNT
(Bank/Utilities)
TRANSFER PROPERTY
(Car/Real Estate)
MEDICAL REASONS
(Medical History)
SOCIAL SECURITY BENEFITS PASSPORT
NAME CHANGE
(marriage certificate only)
PUBLIC RECORD REQUEST
(Records at least 25 years old)
VETERANS BENEFITS ONLY
OTHER (explain)
CERTIFICATION
REQUESTER SIGNATURE
I understand that making a false application for a vital record is a felony under state and federal law. I also certify and affirm that all information presented in this
form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and
accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this
form is a criminal violation.
DATE (mm/dd/yyyy)
DMV USE ONLY
ID Documents Requester Presented (must be 1 primary or 2 secondary documents from the list on the back)
CSR STAMP
PRIMARY 1 or SECONDARY 1 SECONDARY 2
Type of Identification
Expiration Date
Document Number
CSR SIGNATURE
FUNERAL DIRECTOR AND REPRESENTATIVE SIGNATURE (if applicable)
MARRIAGE - DIVORCE - DEATH CERTIFICATE
VIRGINIA VITAL RECORD APPLICATION
NOTE: Fees paid for a vital records search/document are non-refundable. Virginia statutes require a fee of $14.00 (which includes a $2.00 administration fee) for
each search regardless of whether a certification of a vital record is completed or not found. If paying by check or money order, make payable to the
Department of Motor Vehicles (DMV). There is an $85.00 service charge for returned checks. The State Registrar of Vital Records reserves the right to
accept or deny any application (Virginia Code §32.1-271 (C)).
Purpose: Customers use this form to request a Virginia death, marriage or divorce certificate in person.
Instructions:
The requester - the person submitting this application - must show an acceptable identification document(s) from the list on the back of this form and
provide payment to the Department of Motor Vehicles (DMV). Submit to any DMV Customer Service Center.
DL 82 (08-10-2019)
(The acceptable documents listed may change without prior notice.)
PRIMARY DOCUMENTS
Driver's license issued by a U.S. state, territory, or jurisdiction unexpired or
expired for not more than one year
Learner's/instruction permit issued by a U.S. state, territory, or jurisdiction
unexpired or expired for not more than one year
Photo identification card issued by a U.S. state, territory, or jurisdiction
unexpired or expired for not more than one year
Current Photo ID card, (school and employment with identification number).
Check Cashing Cards are not acceptable
Unexpired U.S. military ID card of an active duty or retired member
U.S. Passport or passport card - unexpired
Unexpired Foreign Passport with VISA, I-94 or I-94W
U.S. Certificate of Naturalization - (form N-550, N-570 or N-578)
U.S. Certificate of Citizenship - (form N-560 or N-561)
U.S. Citizen Identification Card - (form I-197)
Temporary Resident Card - unexpired - (form I-688)
Employment Authorization Card - unexpired - (form I-688A, I-688B or I-766)
Refugee Travel Document - unexpired - (form I-571)
Resident Alien Card - unexpired - (form I-551)
Permanent Resident Card - unexpired - (form I-551)
Northern Marianas Card - unexpired - (form I-551)
Asylum - A copy of the first and last page of application for Asylum
Consular Report of Birth Abroad (form FS-240)
Certificate of Birth Abroad (FS-545)
Certification of Report of Birth of a U.S. Citizen (DS-1350)
Virginia Criminal Justice Agency Offender Information Form
United States Probation Offender Information Form
SECONDARY DOCUMENTS
U.S. Selective Service Card
U.S. military discharge papers (form DD214)
Certified School Records/Transcript issued by a U.S. state or territory
Certificate of Enrollment issued by Virginia Department of Education
Life insurance policy
Health care insurance card - (i.e. Medicare Card/ Medicaid Card)
Unexpired welfare/social services identification card with photo, issued by a
municipality
State-issued driver's license or learner's/instruction permit, with photo, expired
not more than 5 years
State-issued photo identification card expired not more than 5 years
U.S. Passport or passport card - expired not more than 5 years
Unexpired military dependent ID card, with photo
Foreign Passport - expired not more than 5 years, with a U.S. VISA ·
Unexpired weapons or gun permit issued by federal, state or municipal
government
Unexpired pilot's license
Veterans' Universal Access Identification Card
INS form I-797 (applicable only for individuals whose names appear on the
form)
USCIS student or dependent SEVIS I-20 with or without USCIS stamp
(Applicant's name must appear on the form)
U.S. Department of State form DS-2019 (Applicant's name must appear on the
form)
Name: Make sure that your name appears the same on all proof documents. If
your middle name or middle initial begins with the same letter, but is not spelled
out or displayed on all of your documents, your documents may be accepted.
Nicknames will not be accepted. If your name appears differently on your proof
documents, you may be asked
to present additional documentation.
- Documents must be originals. Temporary documents and photocopies will
not be accepted.
- All documents are subject to verification with the issuing entity, which may
delay the issuance of your certification.
- A document will not be accepted when there is reason to believe it has been
altered, fraudulently obtained or is fake, forged, counterfeit, or otherwise non-
genuine or illegitimate. Altering, manufacturing, selling or possessing a
fraudulent birth certificate, driver’s license or ID card, falsifying information or
assisting a person with improperly or fraudulently obtaining a certification is a
criminal offense.
The following is a list of Primary and Secondary documents which are acceptable to Virginia Department of Health, Division of Vital Records for the
purpose of certifying a marriage, divorce or death and/or producing a certificate. One Primary Document or two Secondary Documents must be
submitted in order to conduct a certification.
ACCEPTABLE IDENTIFICATION DOCUMENTS
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Dl82 VIRGINIA VITAL RECORD APPLICATION (Virginia Department of Motor Vehicles)

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Completed 30 July 2020

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