Vs 6 Form Virginia – Fill Out and Use This PDF

VS6-2/06

COMMONWEALTH OF VIRGINIA

Application for Certification of a Vital Record

Virginia statutes require a fee of $12.00 be charged for each certification of a vital record or for a search of the files when no certification is made. Please make check or money order payable to State Health Department. There is a $50.00 service charge for returned checks.

Name of Requester: ________________________________________________ Daytime Phone Number (______)___________________________

(person requesting the certificate)

Address: ________________________________________________ City: ___________________________ State: __________________ Zip: ___________________

What is your relationship to the person named on the certificate? (Check one)

____ Self _____ Mother ____ Father _____ Child ______ Current Spouse ____ Sister _____ Brother _____ Maternal Grandparent

_____ Paternal Grandparent ______Legal Guardian (submit custody order) _____ Other (Specify) _________________________________

What is your reason for requesting this certificate? ____________________________________________________________________

I understand that making a FALSE application for a vital record is a FELONY under state and federal law.

Signature of Requester: ___________________________________________________________________________

IMPORTANT: The person requesting the vital record must submit a copy of their identification. See list on reverse side.

BIRTH CARDS ARE NO LONGER AVAILABLE.

BIRTH

Number	Name at Birth:
of Copies	If name has changed since birth due to adoption, court order, or any reason
Paper: ____________	other than marriage, please list changed name here:
	_________________________________________________________________________________
	Date of Birth:					Race:			Sex:
	Place of Birth:				Hospital of Birth:
			(City/County in Virginia)
	Full Maiden Name of Mother:
	Full Name of Father: _______________________________________________________________

DEATH	STILLBIRTH
Number	Name of Deceased: ________________________________________________________________
of Copies: ___________
	Date of Death:			Age at Death:			Race:		Sex: __________
	Place of Death:					Hospital Name: ______________________

				(City/County in Virginia)
	Full Maiden name of Mother: _______________________________________________________
	Full Name of Father: _______________________________________________________________
MARRIAGE
Number	Full Name of Husband:
of Copies: ____________
	Full Name of Wife:
DIVORCE
Number	Marriage - Date:					Place:
of Copies: ____________
	Divorce - Date:					Place:
							(City/County in Virginia)
	If Marriage, place where license was issued: _____________________________________________

Please indicate the address you wish the certificate(s) mailed to in the box below. -- Please type or print clearly.

Name	Send Completed Application To:
Address	Division of Vital Records
	P. O. Box 1000
	Richmond, VA 23218-1000
City/State/Zip	(804) 662-6200
	www.vdh.virginia.gov

The State Registrar reserves the right (§32.1-271C) to accept or deny any application submitted.

ACCEPTABLE IDENTIFICATION

SUBMIT ONE (1) DOCUMENT FROM THE PRIMARY LIST OR TWO (2) DOCUMENTS FROM THE SECONDARY LIST.

The acceptable documents listed may change without prior notice.

PRIMARY LIST

1.Photo Drivers License issued by US DMV office - unexpired or expired for not more than one year

2.Photo Learners/Instruction Permit issue by US DMV office -unexpired or expired for not more than one year

3.Photo Identification Card issued by US DMV Office - unexpired or expired for not more than one year

4.Current Photo Identification Card - (school, employment). Check Cashing Cards are not acceptable

5.Military Card - unexpired - active duty or retired member

6.U.S. Passport – unexpired

7. Foreign Passport with Visa, I-94 or I-94W - unexpired

8.U.S. Certificate of Naturalization - (form N-550, N-570 or N-578)

9.U.S. Certificate of Citizenship - (form N-560 or N-561)

10.U.S. Citizen Identification Card - (form I-197)

11.Temporary Resident Card - unexpired - (form I-688)

12.Employment Authorization Card - unexpired - (form I-688A, I-688B)

13.Refugee Travel Document - unexpired- (form I-571)

14.Resident Alien Card – unexpired - (form I-551)

15.Permanent Resident Card - unexpired - (form I-551)

16.Northern Marianas Card - unexpired - (form I-551)

17.Asylum - A copy of the first and last page of application for Asylum

18.Birth Abroad (Consular Report) of a Citizen of the U.S.A. (form FS-240)

19.Birth Abroad (Certification of Report) of a Citizen of the U.S.A.

20.Virginia Criminal Justice Agency Offender Information Form

21.United States Probation Offender Information Form

SECONDARY LIST

22.U.S. Selective Service Card

23.U.S. Military Discharge Papers - (form DD214)

24.Certified School Records/Transcript issued by a U.S. state or territory

25.Enrollment, Certificate of - issued by VA Dept of Education

26.Life insurance policy

27.

HEALTH CARE INSURANCE CARD

28.Welfare/social services identification card with photo - unexpired – issued by municipality

29.Photo Drivers License - issued by US DMV office expired not more than 5 years

30.Photo Learners/Instruction Permit - issued by US DMV office expired not more than 5 years

31.Photo Identification card - issued by US DMV office expired not more than 5 years

32.U. S. Passport - expired not more than 5 years

33.Foreign Passport - expired not more than 5 years, with a VISA,

34.	Military dependent ID card, with photo - unexpired
35.	Weapons or gun permit issued by federal state or municipal government-unexpired
36.	Pilots License – unexpired
37.	INS form I-797 (applicable only for individuals whose names appear on the form)
38.	IAP-66 U.S. Department of State form (applicable only for the individuals whose names
	appear on the form).
39.	Veterans Universal Access Identification Card