Jackson County Public Health Application for a Vital Record

Jackson County Public Health Application for a Vital Record
If eligibility requirements are met and a record is found, applicant is entitled to certified copies. FEE MUST ACCOMPANY APPLICATION.
I will pay by Debit/Credit Card*

YesNo
Death Information
Did the death occur in Missouri?*

YesNo
Number of Copies *
(First copy issues $14; Each additional copy $11)
Name on Certificate*

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

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

FemaleMale
Race*
Full Name of Spouse*
If none, type N/A
Full Maiden Name of Mother*
Full Name of Father
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

Death certificates are $14 for the first one and $11 for each additional 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

Please DOUBLE CHECK the information you enter into the form above BEFORE you hit submit. Please contact the vital records division at 816-404-6419 for questions. 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 death 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

Death Information

Additional Information

Payment Information

Please DOUBLE CHECK the information you enter into the form above BEFORE you hit submit. Please contact the vital records division at 816-404-6419 for questions. If you are in need of assistance with transportation, please call or text us at 816-447-0421.