Jackson County Public Health Application for a Vital Record

Jackson County Public Health Application for a Vital Record
As of March 2021 per The State of Missouri Bureau of Vital Records, if a child is born to unmarried parents, the name of the father/information will be delayed on certificate of birth. For any additional questions or concerns please contact:

Bureau of Vital Records (Amendment Unit) 573-751-6378
If eligibility requirements are met and a record is found, applicant is entitled to certified copies. FEE MUST ACCOMPANY APPLICATION. Birth records from 1920 to present.
I will pay by Debit/Credit Card*

YesNo
Birth Information
Did the birth occur in Missouri?*

YesNo
Number of Copies *
($15 per copy)
Name on Certificate*

First NameMiddle NameLast Name
Also known as:
(Indicate if birth could be recorded under another name)
Date of Birth*

MonthDayYear
Date
Place of Birth*
(City, County, State)
Hospital
Sex:*

FemaleMale
Full Name of Parent One (Birth Name)*
Full Name of Parent Two (Birth Name)*
Were the parents married at the time of birth?*

YesNo
Additional Information
Applicant's Name*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose for Certificate Request*
Your Relationship to Person Named on Record*
If legal guardian, you must provide guardianship papers
If Legal Representative, Indicate Legal Relationship
Signature: (Person requesting birth certificate) *

Clear
Payment Information

Birth certificate copies are $15 per copy requested. Online transactions will contain a fee - 0.15% + $0.10 per transaction. If you choose to pay by cash, your vital records WILL NOT be processed until after you pay, resulting in a short wait. PLEASE NOTE: The Jackson County Public Health is operated by University Health. Your statement will reflect a charge from UH/TMC.
I will pay by:*

Credit/Debit Card - Enter Below
I would like to make a $1.00 donation to support homeless families & provide financial assistance to organizations addressing homelessness in Jackson County.

YesNo

Please DOUBLE CHECK the information that you enter BEFORE you submit your requests. You may call the vital records division at 816-404-6419 with questions or concerns. If you are in need of assistance with transportation, please call or text us at 816-447-0421.
You have 1 calendar year to pick up your purchased records. All birth certificates will be destroyed if not picked up within 1 year. There will not be a refund issued due to the cost to issue a record.
Should be Empty:

Jackson County Public Health Application for a Vital Record

Birth Information

Additional Information

Payment Information

Please DOUBLE CHECK the information that you enter BEFORE you submit your requests. You may call the vital records division at 816-404-6419 with questions or concerns. If you are in need of assistance with transportation, please call or text us at 816-447-0421.