Applicant
Name:
Daytime
Telephone:
Street
Address:
City, State,
and ZIP:
Relationship
to Registrant:
Michael Butler
Recorder of Deeds
City of Saint Louis
City Hall, Room 126
1200 Market Street
Saint Louis, MO 63103
314.613.3015
Important Instructions:
1.) Mail-in Requests must be NOTARIZED.
2.) A non-refundable $15.00 fee is required for
each certied copy, per State statute.
If a record is found, one (1) certied copy will be mailed.
3.) Include either a self-addressed, stamped envelope,
or add 55¢ to payment for postage.
Birth Records Dept.
City Hall, Room 126
1200 Market Street
Saint Louis, MO 63103
Mail Application
for Certied
Birth Certicate
For any Missouri Birth, 1920 - Present
No. of Copies
requested:
Birth Registrant
Name at Birth:
Place
of Birth:
Date of
Birth:
Father’s First
and Last Name:
Mother’s First
and Maiden Name:
I, _____________________________________, subject to
penalty of perjury, do solemnly declare and arm that I am
eligible to receive a certied copy of the vital record(s)
requested and that the information contained in my
request is true and correct to the best of my knowledge.
Applicant MUST sign and date this statement
in front of a Notary Public:
Applicant Signature Date
SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME,
Notary Public Signature
MY COMMISSION EXPIRES:
(To be completed by Notary):
STATE COUNTY
THIS DAY OF , 20
Notary Public Name, Typed or Printed
Notary Public Embosser Seal or Rubber Stamp:
First Middle Last
City and County
Applicant Information:
(Customer)
Registrant Information
(Name on Birth Record)
Make checks payable to “Vital Records”.
Please mail payment (Check or Money Order), along with
Completed & NOTARIZED form and either a Self-Addressed,
Stamped envelope, or an additional 55¢ for postage) to:
