Form Adph Hs14 – Fill Out and Use This PDF

USE ONLY FOR A VITAL EVENT WHICH OCCURRED IN ALABAMA

The fee for a birth, death, marriage or divorce record search is $15.00, which includes the cost of one certified copy OR Certificate of Failure to Find. For additional copies of the same record ordered at the same time, the fee is $6.00 each. For information on how to expedite a document, call 334-206-5418. Amendments, adoptions, legitimations, and delayed certificates must be processed through the Center for Health Statistics. The fee is $20.00 to amend a record or file a delayed certificate which also covers the cost of one certified copy of the record. The fee is $25.00 to prepare a new certificate of birth after adoption or legitimation which also covers the cost of one certified copy of the record. Make check or money order payable to the "State Board of Health." Fees are non-refundable. Do not request two different types of certificates on the same

form. PRINT ALL INFORMATION LEGIBLY. You must complete & sign the applicant section or your request cannot be processed.

TAKE THIS FORM TO YOUR LOCAL ALABAMA COUNTY HEALTH DEPARTMENT OR MAIL THIS FORM TO:

Alabama Department of Public Health, Center for Health Statistics, P.O. Box 5625, Montgomery, Alabama 36103-5625

For information on ordering a vital record via the Internet, visit our web site at: http: //www.adph.org

APPLICANT SECTION (THIS SECTION MUST BE COMPLETED) Birth certificates less than 125 years old and death certificates less than 25 years old are restricted records. You must be an immediate family member OR demonstrate a legal right to the record in order to obtain a copy of the record (§ 22-9A-21). Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up to $500. Code of Ala. 1975, § 13A-10-109. By signing, you are certifying you have a legal right to the record requested.

Your Signature________________________________________________________________________________Date________________________________________

Print Your Name _________________________________________________________________________ Address _____________________________________________________________

City _____________________________________________________ State________ Zip__________________ Daytime Phone (____________)______________________________________________

Your Relationship to Person Whose Record is Being Requested _________________________________________________________________________________

Reason for Request (if not immediate family)___________________________________________________________________________________________________

I allow the following individual to pick up the certificate(s)________________________________________________________________________________________

BIRTH:NUMBER OF COPIES _____________________ AMOUNT PAID $____________________________

FULL NAME AS ON

BIRTH CERTIFICATE______________________________________________________________________________________________________________________________________________

FIRST	MIDDLE	LAST
DATE OF BIRTH __________________________________________________________________________SEX____________________________________________________________________
COUNTY OF BIRTH ____________________________________________________________________ HOSPITAL________________________________________________________________
FULL MAIDEN NAME OF MOTHER__________________________________________________________________________________________________________________________________
FIRST	MIDDLE	LAST
FULL NAME OF FATHER___________________________________________________________________________________________________________________________________________
FIRST	MIDDLE	LAST
DEATH:	NUMBER OF COPIES _____________________	AMOUNT PAID $____________________________
LEGAL NAME OF DECEASED______________________________________________________________________________________________________________________________________
FIRST	MIDDLE	LAST

DATE OF DEATH ____________________________________ COUNTY OF DEATH ______________________________________________ SEX______________________________________

SSN ___________________________________________________ DATE OF BIRTH OR AGE ________________________________________ RACE___________________________________

NAME OF SPOUSE_______________________________________________________________________________________________________________________________________________

		FIRST		MIDDLE	LAST
NAME OF PARENTS________________________________________________________________________________________________________________________________
STARTING WITH 1991 DEATHS, CERTIFICATES MAY BE ISSUED WITHOUT A CAUSE OF DEATH. Indicate the number of copies of each type of certificate
you want:		WITH CAUSE OF DEATH		WITHOUT CAUSE OF DEATH

FULL NAME OF HUSBAND____________________________________________________________________________________________________________________________

FIRSTMIDDLELAST

FULL MAIDEN NAME OF WIFE_________________________________________________________________________________________________________________________

FIRSTMIDDLELAST

DATE OF MARRIAGE_______________________________________________ (OR) DATE OF DIVORCE____________________________________________________________

IF MARRIAGE, COUNTY WHERE LICENSE WAS ISSUED_____________________________________________________________________________________________________________

IF DIVORCE, COUNTY OF DIVORCE________________________________________________________________________________________________________________________________

COUNTY REGISTRAR USE: This application has been reviewed for the individual's right to receive the requested document(s).

_____________________________________________________________________	_________________________ ___________________________________________________________
County Registrar's Signature	Date	County Health Department Receipt Number
Informational materials in alternative formats will be made available upon request.		ADPH-HS14/Rev. 10-01-2009