Professional Documents
Culture Documents
This request must be accompanied by a fee of $13.00 per Last Name ___________________________________
copy. A money order or personalized check from the
person making the request should be made payable to
If this record could be recorded under any other name,
VITAL RECORDS SERVICES
list that name here
If you do not have a birth record on file, you will be sent
instructions for filing a Delayed Birth Certificate, and ______________________________________
your $13.00 fee will be retained as a searching fee.
Date of Birth Sex
_____/_____/____ Male Female
Enclosed is $________ for _____certified copy/copies
Place of Birth
Please enclose a self-addressed stamped envelope _____________________, WY
with the application.
Mother’s Full Maiden Name
____________________________________
____________________________________