Columbia/Boone County Public Health & Human Services
1005 West Worley
|
Columbia, MO 65203
|
573-874-6396
Full Name on Cercate:
For Birth Cercates - Date of Birth (month/day/year):
For Death Cercates - Date of Death (month/day/year):
Full Name of Parent 1 (Last name before marriage/domesc partnership):
Full Name Parent 2 (Last name before marriage/domesc partnership):
YOUR
CURRENT
INFORMATION
Your
Name:
Your Phone Number:
(with area code)
Your
Address:
City, State/Zip:
I, the undersigned, subject to penalty of perjury, do solemnly declare and affirm that I am eligible to receive a certified copy of the vital
record (birth or death certificate) requested above and that the information contained in this application is true and correct to the best
of my knowledge.
YOUR SIGNATURE: ______________________________________TODAY’S DATE: _____________
Your Relaonship
to Person Named
on Cercate
-
In person - must
submit photo ID
☐ Self ☐ Child ☐ Grandchild ☐ Other (specify)
__________________
☐ Parent ☐ Sister ☐ Current Spouse
☐ Grandparent ☐ Brother ☐ Legal Guardian (with judgement of custody
Missouri Birth and Death Certificate Application
Which cercate do you need? ☐ Birth Cercates
$15 each
☐ Death Cercates
$13 for 1st copy
$10 for each extra copy
How many copies do you need? ____________ ___________
STOP HERE UNLESS MAILING APPLICATION
• If mailing applicaon, send to: Columbia/Boone County Department of Public Health and Human Services, 1005 W.
Worley, Columbia, MO 65203.
• Mailed applicaons must be signed and notarized, and include a check or money order payable to City of Columbia.
• Please include a stamped, self-addressed envelope.
State of ______________________
County of ____________________
On this __________ day of __________________ in the year _____________,
before me, the undersigned notary public, personally appeared
_________________________________________________________, known
to me to be the person(s) whose name(s) is/are subscribed to the within
instrument and acknowledged that he/she/they executed the same for the
purposes therein contained. In witness whereof, I hereunto set my had and
ocial seal.
_______________________________________________________________
Notary Public
Notary Embosser Seal or Black Rubber Stamp Below
