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Deathfmnew 240720 201839

This document is an application form for obtaining a copy of a West Virginia death certificate, outlining the necessary information about the deceased and the requester. It specifies who is entitled to request the records and the required identification documents needed for the application. Additionally, it includes instructions for submitting the application along with payment and contact information for the Vital Registration office.

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3 views2 pages

Deathfmnew 240720 201839

This document is an application form for obtaining a copy of a West Virginia death certificate, outlining the necessary information about the deceased and the requester. It specifies who is entitled to request the records and the required identification documents needed for the application. Additionally, it includes instructions for submitting the application along with payment and contact information for the Vital Registration office.

Uploaded by

juliehannah01101973
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application for Copy of West Virginia Death Certificate

Please 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 Death

First Middle Last Month/Day/Year

City County State Sex:


Male Female

The information below pertains to the person requesting the certificate.

Requestor’s Relationship: Parent Guardian or agent Grandparent

Child of decedent Spouse

Other (Describe)

Making false statements and misuse of vital records will result in criminal and civil penalties pursuant
to WV Code §16-5-38.

Signature (Required) Printed Name (Required)

Reason for request:

Enclosed is $___________ for _______ copies at $12.00 per copy.

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 01/06/09
Death records are confidential and not open to the general public, except for those that are at least 50 years old.

Who is entitled to obtain records:

● Informant listed on the death certificate;


● Parents/grandparents;
● Adult children/grandchildren;
● Adult siblings;
● Spouse; and
● Legal representatives (proof of legal representation also required).

Proof of relationship may also be required.

All requests must be accompanied by a valid ID as listed below. The acceptable documents listed may change without
prior notice. For mail requests, a photocopy of the document is sufficient, please do not send the original.

Submit one (1) document from the primary list OR two (2) documents from the secondary list.

Primary Documents

● DMV-issued driver's license unexpired or expired for not more than five years;
● DMV-issued learner's/instruction permit unexpired or expired for not more than five years;
● DMV-issued photo identification card (excluding child ID cards) unexpired or expired for not more than one year;
● Current Photo ID card, (school and employment). Check Cashing Cards are not acceptable;
● Unexpired U.S. military ID card of an active duty or retired member (ID cards of military dependents are not
acceptable as primary identity documents);
● U.S. Passport unexpired or expired for not more than five years;
● West Virginia Criminal Justice Agency Offender Information Form; or
● United States Probation Offender Information Form

Secondary Documents (Require two of below selections)

● Social Security Card


● A utility bill (phone, electric, gas, water, etc.) with your name and current address;
● Automobile registration with your name and current address;
● Automobile insurance card with your name and current address;
● Voter’s Registration Card with your name and current address;
● Checking account deposit slip or bank statement stating name and current address;
● Paycheck stub or a W-2 form with your name and current address;
● U.S. Selective Service Card;
● U.S. military discharge papers (form DD214);
● Health care insurance card;
● Unexpired welfare/social services identification card with photo, issued by a municipality;
● Unexpired weapons or gun permit issued by federal, state or municipal government; or
● Veterans’ Universal Access Identification Card.

WV Vital Registration
350 Capitol St. Rm. 165, Charleston, West Virginia, 25301-3701
Information Line: (304) 558-2931

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