Applications for a Vital Record

You can download the Application for Certification of a Vital Record form in:

MS Word for Windows format
Download the Application for Certification of a Vital Record and ID Requirements form in MS Word format. The file will come up and you have the choice of either printing the file or saving it to your disk by selecting: File/Save As on your desktop. If you are unable to download the application form, please write us and include the necessary information that is listed on the Mail It In page. En Español

PDF format (requires Adobe Reader)
Download the Application for Certification of a Vital Record form. En Español You can download a FREE copy of Adobe Reader and follow the easy instructions. Adobe Reader is required to view the form.

If you provide your email address in the application, you will receive email updates on the status of your application along with your Application Tracking ID.

How to Complete a Check for the Office of Vital Records?

Below is a diagram of a check with all the different parts of the check labeled. Instructions for each numbered item are below the check.

  1. This is the information of the person writing the check. It must include full name and complete address.
  2. This is the date that the check is written. The date can be spelled out such as "July 8, 2019" or by using numbers such as "7/8/2019.” Please no post-dated checks.
  3. This is to whom you are writing the check. Checks should be made payable to State Health Department.
  4. This is the amount of money the check is for. In this box, the amount is written in numbers. For example, 12.00.
  5. This is also the amount of money the check is for, but this time the amount is written in words. For example, twelve dollars and 00/100. The 00/100 represents zero cents.
  6. This is a memo. The memo line is mostly used as a reminder of what the check was for.
  7. This is where the checked is signed. The signature should match the name(s) in Part 1.

*Starter Checks are not accepted.

**There is a $50.00 service charge for returned checks.

How to Complete a Money Order for the Office of Vital Records?

Below is a diagram of money orders with all the different parts of the money order labeled. Instructions for each numbered item are below the money order.

  1. Write the name of where the money order is going. Money orders should be made payable to State Health Department.
  2. Where it says “Purchaser's address,” write in your full address.
  3. Sign the front of the money order. Do not sign on the line on the back of the money order.