vital statistics certificate request - Idaho
IDAHO VITAL STATISTICS CERTIFICATE REQUEST
IDAHO VITAL RECORDS
▪
P.O. Box 83720 y Boise, ID 83720-0036 ▪ (208) 334-5988 y www.healthandwelfare.idaho.gov
Instructions for completing this form are located on the back of this document. Please read these instructions
carefully. Failure to do so may cause a significant delay in processing your request.
YOUR MAILING ADDRESS INFORMATION (PERSON REQUESTING THE CERTIFICATE)
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME
STREET AND NUMBER (P.O. BOX) CITY STATE, ZIP CODE
CONTACT PHONE NUMBER (DAY TIME) YOUR RELATIONSHIP TO PERSON NAMED ON CERTIFICATE (SELF, MOTHER, ETC.)
PURPOSE FOR THE CERTIFICATE
SIGNATURE OF THE PERSON REQUESTING THE CERTIFICATE:
►
REQUESTS MUST INCLUDE A COPY (FRONT AND BACK) OF A CURRENT GOVERNMENT-ISSUED SIGNED PICTURE ID OF THE PERSON REQUESTING THE
CERTIFICATE.
(SEE INSTRUCTIONS ON THE BACK OF THIS DOCUMENT)
IMPORTANT: BIRTH, DEATH, STILLBIRTH, MARRIA E OR DIVORCE MUST HAVE OCCURRED IN G IDAHO.
5
INDICATE CERTIFICATE REQUESTED:
BIRTH
STILLBIRTH
Available from July 1911
NAME ON CERTIFICATE:
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME
DATE OF BIRTH CITY OF BIRTH NUMBER OF COPIES YOU ARE REQUESTING
FATHER’S NAME:
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME
MOTHER’S MAIDEN NAME:
FULL FIRST NAME FULL MIDDLE NAME
FULL LAST MAIDEN NAME
DEATH Available from July 1911
NAME ON CERTIFICATE:
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME
DATE OF DEATH CITY OF DEATH NUMBER OF COPIES YOU ARE REQUESTING
5
INDICATE CERTIFCATE REQUESTED:
MARRIAGE DIVORCE
Available from May 1947
HUSBAND’S NAME:
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME
WIFE’S NAME:
FULL FIRST NAME FULL MIDDLE NAME FULL LAST NAME (at time of event)
DATE OF EVENT CITY OF EVENT NUMBER OF COPIES YOU ARE REQUESTING
# of copies FEES* $ cost
BIRTH-STILLBIRTH-MARRIAGE-DIVORCE CERTIFIED COPY @ $13.00 EACH
DEATH CERTIFIED COPY @ $14.00 EACH
BIRTH-STILLBIRTH-MARRIAGE-DIVORCE CERTIFIED PHOTOCOPY
@ $13.00 EACH + $5.00 PROCESSING FEE
DEATH CERTIFIED PHOTOCOPY @ $14.00 EACH + $5.00 PROCESSING FEE
SPECIAL HANDLIN
G @ $5.00 (RUSH ORDERS ONLY)♦
PROCESSING FEE FOR LEGAL ACTIONS @ $13.00 EACH
TOTAL ENCLOSED
*
See the back of this document for further instructions,
information, and explanation of fees.
♦
If you would like to RUSH your order, please include a
one-time charge of $5.00 (per order) and write RUSH on
the outside of your envelope. There is no shipping charge
for regular mail. If express mail is desired, you may
express mail your request to us and include a prepaid
express mail envelope back to yourself. We cannot send
your order C.O.D.
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