Application For Copy Of Birth Or Death Certification
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1Warren County Health Department
Certificate # ______________________
101 Mockingbird Lane, Ste. 100
Processor ________________________
Warrenton MO 63383
Date ____________________________
Phone: 636-456-7474
APPLICATION FOR COPY OF BIRTH OR DEATH CERTIFICATION
The Warren County Health Dept. can access Missouri Birth records after 1920 and Death records after 1980. All other
requests must be sent to the State Bureau of Vital Records. We accept cash, checks & money orders (payable to Warren
County Health Dept.) or credit cards (processing fee applies). Fee must accompany mailed application.
BIRTH RECORD ___Quantity
DEATH RECORD ____ Quantity
$13 Fee for a Death Certificate. $10 Fee for each additional
copy of the same record ordered at the same time.
$15 Fee for each copy of a Birth Certificate
Name on Certificate (First)
( Middle)
(Last)
Name on Certificate (First)
( Middle)
(Last)
Also Known As
Date of Death (Month)
(Day)
(Year)
(Indicate if Birth could be under another name)
Sex Male
Sex Male
Female
Female
Date of Birth (Month)
(Day)
(Year)
Place of Death (City)
(County)
(State)
Place of Birth (City)
(County)
(State)
Spouse’s Name (First)
(Middle)
(Last)
Father’s Name (First)
(Middle)
(Last)
Father’s Name (First)
(Middle)
(Last)
Mother’s (Maiden) Name (First)
(Middle)
( Last)
Mother’s (Maiden) Name (First)
( Middle)
( Last)
APPLICANT’S INFORMATION
Your Signature
Please PRINT Name
Daytime Phone
(
)
Your Address
(Street or PO Box)
(City)
(State)
(ZIP)
Purpose for which certified copy is to be used.
Your relationship to person named on certificate (self, mother, father, spouse, guardian, etc.)
(if legal guardian, must provide guardianship papers):
Section Below is ONLY required for Mail-In Requests!
Notary Public Embosser Seal
State
County
SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME,
USE RUBBER STAMP IN CLEAR AREA BELOW
THIS___________DAY OF ___________, 20______
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME (PLEASE PRINT NAME)
Mail-In Request MUST be notarized and application signed. Cash is not accepted for mailed applications.
Enclose self-addressed stamped envelope with adequate postage for requested number of copies.
*WARNING: False application for a certified copy of a vital record is a felony punishable by a fine up to $5,000, five years in prison, or both (RSMo 193.315)
Revised 08/27/14
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