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Birth Certificate App

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VS-37 (Rev 1/30/2012)

BIRTH

COMMONWEALTH OF KENTUCKY STATE REGISTRAR OF VITAL STATISTICS  APPLICATION FOR A CERTIFIED COPY OF BIRTH CERTIFICATE Certificates of Birth that occurred in Kentucky since 1911 are on file in this office Please Print or Type All Information Required On This Form

BIRTH CERTIFICATE INFORMATION First

1. Full Name at Birth

 Month

2. Date of Birth

3. Place of Birth

Middle

Day

Last

Year

Sex

Age Last Birthday

Kentucky City or Town

Kentucky County

Name of Hospital

First

Middle

Last

First

Middle

Last

4. Mother’s Maiden Name 5. Father’s Name

If this child has been adopted, please give original name if known:  _____________________________________________________  _____________________________________________________

DO NOT WRITE IN THIS SPACE

What is your relationship to the person whose certificate is being requested?  _____________________________________________________  ________________________________________ _____________ Signature and telephone number of the person requesting this t his certificate:

Volume Certificate Year Date Searched by

 _____________________________________ ___________________ Signature Telephone  _______________________________________________________________________________  ________________________________________ _____________________________________________________________ ______________________ Certificates may also be ordered by the following methods:

FEES

Internet:  Certificates may be ordered on the internet using a credit card (Visa, MasterCard, Discover or American Express) or check. An additional charge card fee will apply. This is in addition to the fee for each certified copy requested. Certificates requested via internet,, www.vitalchek.com/kentucky-express-birth-certificates.aspx , may be returned by internet overnight courier for the cost of the additional shipment fee if that record is available. Telephone: Orders may be placed by telephone using a credit card (Visa, MasterCard, Discover or American Express) or check.   An additional charge card fee will apply. This is in addition to the fee for each certified copy requested. Certificates requested via telephone may  be returned by overnight overnight courier for for the cost of the additional additional shipment fee. The telephone telephone number to place your order is (800) 241-8322, choose option 1. Mail: Orders are accepted by mail, using a check or money order in U.S. dollars drawn on a U.S. bank for payment. It can take up to 30 working days to process your request from the date payment is posted. Mail to Vital Statistics, 275 East Main Street 1E-A, Frankfort, KY 40621. The Office of Vital Statistics telephone number is (502) 564-4212.

A fee is to be paid for certified copies or records, or for a search of the files or records when no copy is available. The fee for a certified copy of a birth certificate is $10.00 U.S. Additional copies are $10.00 U.S. each. Make check or money order payable to “Kentucky State Treasurer.” This fee is non refundable.  ________ Certified Copies @ $10.00 each How many

Total Amount Enclosed  __________  

Walk-in:   You may order a certified copy of the birth record by coming to this office. The office is located at the address above. Orders are accepted for same day issuance from 8:00 AM until 3:30 PM Monday through Friday.  _____________________  ___________ ______________________ _______________________ _______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _______________________ _______________ ____

THIS SECTION MUST BE COMPLETE FOR ALL ORDERS REQUESTORS INFORMATION:

__________________________  __________________________  __________________________ __________________________ 

 NAME  MAILING ADDRESS CITY, STATE, ZIP CODE

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