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 a Certificate of Failure
to Find. For additional copies of the same record ordered at the same time, the fee is $6.00 each. 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.” Do not send cash. 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 expediting a request or ordering online, visit our website at
http://www.alabamapublichealth.gov/vitalrecords or call 334-206-5418.
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. Valid identification must be submitted with a request for a restricted record. 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 receive certificate(s) ___________________________________________________________________________
BIRTH: SEE ID REQUIREMENTS ON REVERSE SIDE
NUMBER OF COPIES
_______________
AMOUNT PAID $
_________________
FULL NAME AS ON
BIRTH CERTIFICATE
___________________________________________________________________________________________________
FIRST MIDDLE LAST
DATE OF BIRTH _____________________________________________________________________ SEX______________________
COUNTY OF BIRTH
_____________________________________________HOSPITAL________________________________________________
FULL NAME OF MOTHER/PARENT
BEFORE FIRST MARRIAGE __________________________________________________________________________________________
FIRST MIDDLE LAST
FULL NAME OF FATHER/PARENT
BEFORE FIRST MARRIAGE
__________________________________________________________________________________________
FIRST MIDDLE LAST
DEATH: SEE ID REQUIREMENTS ON REVERSE SIDE
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
___ MARRIAGE OR ___ DIVORCE:
NUMBER OF COPIES
_______________
AMOUNT PAID $
_________________
FULL NAME OF HUSBAND/SPOUSE
BEFORE FIRST MARRIAGE
______________________________________________________________________________________________
FIRST MIDDLE LAST
FULL NAME OF WIFE/SPOUSE
BEFORE FIRST MARRIAGE
______________________________________________________________________________________________
FIRST MIDDLE LAST
IF MARRIAGE, DATE OF MARRIAGE___________________________ COUNTY WHERE LICENSE WAS ISSUED ________________________________
IF DIVORCE, DATE OF 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. 3/2018
IDENTIFICATION REQUIREMENTS FOR RESTRICTED ALABAMA
VITAL RECORDS
Identification is required of any applicant requesting a restricted Alabama vital record
(birth certificate less than 125 years from the date of birth or death certificate less than 25 years
from the date of death). The applicant must submit a completed request and one form of
identification from the Primary ID list below. In the event the applicant is unable to provide
identification from the Primary ID list, he/she may provide two different forms of identification
from the Secondary ID list.
If the applicant designates another individual to pick up a restricted certificate on his/her
behalf, both the applicant and the designee must provide acceptable identification.
The completed request, as well as a copy of all identification submitted, will be
maintained by the vital records office which processes the request.
Primary IDs Including PHOTO
(need at least one, current, expired no more than 60 days)
Secondary IDs
(need at least two)
- Alabama Driver’s License
- Out-of-State Driver’s License
- State-Issued Non-Driver ID
- U.S. or Foreign Passport
- U.S. Certificate of Naturalization
- Certificate of Citizenship
- U.S. Military ID
-
Work ID (If applicant is employee of
agency/company making request)
- Alien Resident Card (Temporary or
Permanent)
- U.S. Employment Authorization Card
- Citizenship ID Card
- Tribal ID
- Pilot’s License
- Boating License
- Concealed Weapons License
- Ex-Felon ID
- Inmate ID issued by the U.S. Dept of
Justice w/ following documentation:
o Supporting documents from
institution if inmate is still in
custody, letter of release from
institution if inmate has been
released
- School ID (Must include current school
term)
- Alabama Voter Identification Card
- Expired, Government-Issued ID
- Utility Bill (No more than 6 months old)
- Work ID (If applicant is making personal
request)
- Vehicle Registration or Vehicle Title
- Property Tax Bill
- Military Discharge (DD Form 214)
- Voter Registration Card
- Health Insurance Card
- Social Security Correspondence (not
Card)
- U.S. Selective Service Card
- Recent DMV Receipt for Fines Paid
- Fishing or Hunting License
- Copy of Police Report or other official
documents which support theft, in cases
where individual’s ID has been stolen
- Autism Spectrum Card
- Immunization (Shot) Record
*In special cases where applicant is unable to
provide any of these documents, please contact
CHS at 334.206.5418.
