Columbia/Boone County Public Health & Human Services
1005 West Worley
Columbia, MO 65203
Full Name on Cercate:
For Birth Cercates - Date of Birth (month/day/year):
For Death Cercates - Date of Death (month/day/year):
Full Name of Parent 1 (Last name before marriage/domesc partnership):
Full Name Parent 2 (Last name before marriage/domesc partnership):
Your Phone Number:
(with area code)
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 Relaonship
to Person Named
on Cercate
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 cercate do you need? Birth Cercates
$15 each
Death Cercates
$13 for 1st copy
$10 for each extra copy
How many copies do you need? ____________ ___________
If mailing applicaon, send to: Columbia/Boone County Department of Public Health and Human Services, 1005 W.
Worley, Columbia, MO 65203.
Mailed applicaons 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
ocial seal.
Notary Public
Notary Embosser Seal or Black Rubber Stamp Below