APPLICATION FOR A SEARCH FOR AN IOWA VITAL RECORD
REQUESTS REQUIRE THE APPLICANT'S CURRENT GOVERNMENT-ISSUED PHOTO IDENTIFICATION AND SIGNATURE
SIGNED
IN
FRONT OF A NOTARY PUBLIC
OR
IN THE PRESENCE
OF
AN IOWA REGISTRAR OF
VITAL
RECORDS.
• This application is
for
a SEARCH
for
an
Iowa birth, death
or
marriage record. Fees are due upon application.
•
If
requesting a certified
copy
of
a birth record, complete all items except 2(A).
•
If
requesting a certified
copy
of
a death record, complete all items except 2(A) and
7.
•
If
requesting a certified copy
of
a marriage record, complete all items, including 2(A).
•
If
requesting
by
mail, the I.D.
must
be
a clear photocopy and the signature notarized.
1. TYPE OF RECORD REQUESTING (Check one)
:::J
BIRTH
Ll
DEATH
Ll
MARRIAGE
2.
PERSON'S
NAME
AS
IT
APPEARS
ON THE RECORD
FIRST
2a.
If
for
Marriage
record,
SPOUSE'S NAME
FIRST
3. DATE OF EVENT (Birth, Death,
or
Marriage) - BE SPECIFIC - Monlh/DayNear
4.
PLACE
OF EVENT (City and/or County)
5.
MOTHER'S
FULL
MAIDEN
NAME
-
FIRSTlMlOOLE,l
anyIMAJDEN SURNAME (Last)
6. FATHER'S
FULL
NAME - FIRSTlMIDDLE.
hnylSURNAME(LaSl)
MIDDLE, K any
MIDDLE. Kany
SURNAME (Last)
SURNAME
(Last)
IIWIiage
does
NOT
dlange Ihe
biI1ll
C8tificale.
o Legal Change
of
Name on Birth Certificate
7.
8.
(Birth
Only)
WAS THE MOTHER MARRIED AT THE TIME OF CONCEPTION OR BIRTH?
LEGAL
ACTIONS TO RECORD 0 None 0 Adoption 0 Paternity Establishment
8a. IF A
LEGAL
ACTION OCCURRED,
LIST
PREVIOUS
NAME
(on birth cettllicale)
DYes
DNO
DUnknown
9.
PURPOSE FOR
COPY
_
10. BIRTHDATE
of
APPUCANT/RECIPIENT
_
11. RELATIONSHIP OF PERSON RECEIVING THIS
COpy
TO PERSON NAMED ON
THE
RECORD
12.
NAME
AND
ADDRESS
OF
PERSON TO
RECBVE
THIS COPY: (MUST BE AGE
18
OR
OLDER & ENTITLED TO THE RECORD)
12a.
Name
of
Applicant/Recipient
12b.
Street
address
and
P.O. Box (if any)
12c.
City.
State
and
Zip
Code
13. THE SEARCH RESULT
IS
TO
BE
(Check
one)
0 Mailed 0 Picked
up
(forin-jlelSOl1 requests only)
14. THE
NON-REFUNDABLE
FEE
TO
SEARCH
IS
$15.00 and one certified copy is issued
if
the record
is
located.
Each additional copy
of
the same record is $15.00. Indicate
the
number
of
copies
of
this record you need.
15. THIS SEARCH PAID
BY
(Check
one)
0
Check
0 Money Order 0 Cash
~
only) 16.
AMOUNT
ENCLOSED
Checks must
be drawn from the applicants' account; money orders must be in the name of the
applicant
Fee payment must
a=m-pa-n-y--;th;-:j""'s
'fo-rm-.-.
-
17.
APPLICANT'S
NAME
(Print clearly)
18. DAYTIME PHONE
#
-----::{I-=nckJ:l==-e...,-ar...,-ea-cod-:-=e;,.-,
__
I certify that the information provided
on
this application is accurate and complete to the best of
my
knowledge and that I have legal entitlement to a
certified copy
of
this record. I have signed below in front
of
a notary pUblic or an Iowa registrar
of
vital records.
19.
APPUCANrS
SIGNATURE 20. DATE _
Signature
must
be
notarized
if
applying
by
mall
State of _
County
of
ss
(SEAL)
Administrative
Use
Only
Signed and affirmed in
my
presence on this
__
day
of
_
--7.:::=:.====-----.,
My
commission expires: _
Notary Public SignabJre
SEE OTHER SIDE FOR INSTRUCTIONS
1.0. _
Initials
PLEASE SEND TO: PLYMOUTH COUNTY RECORDER, 215 4TH AVE SE Le Mars, IA 51031
PLEASE SEND TO: PLYMOUTH COUNTY RECORDER, 215 4TH AVE SE LE MARS, IA 51031
To
Request
a Search
for
an
Iowa
Birth,
Death
or
Marriage
Record
for
the
Purpose
of
Obtaining
a
Certified
Copy
In
Iowa,
official registration
of
births, deaths, and marriages began July
1,
1880.
Original records that were registered are
on
file
with
the Iowa Department
of
Public Health, Bureau
of
Health Statistics. Statewide record searches are available
from the state registrar. Local vital records registrars are located in county recorders' offices, where records
of
births and
deaths that have occurred
in
that county are maintained. Marriage records are maintained
in
the county where the license
to marry was obtained.
County registrars are
not
authorized
by
law to have records
of
single-parent births
prior
to July
1,1995;
adoptions; delayed registrations; legal changes
of
name;
fetal
deaths (stillborns); any record orderedsealed
by
a court
of
law,'
or
birth, death,
and
marriages between theyears1921 to 1941.
Per
Iowa law. information about a
specific record is not available over the telephone
or
by
prepared lists. Iowa lawprovides for public viewing
in
the county
where the record is maintained,
or
certified copies issued to entitled persons.
Applications
to
search
for
a
vital
record
event
for
the
purpose
of
obtaining
a
certified
copy
must be
in
writing,
completely identify the record, and establish entitlement to the record being requested. Entitled persons include the
person named
on
the record
or
that person's spouse, children, legal parents, grandparents, grandchildren, siblings,
or
legal
representative
or
guardian. Legal guardians and representatives must also provide additional
proof
of
guardianship
or
representation. Applicants must be
18
or
older. Requests must include the applicant's current government-issued photo
identification, except
ifby
mail, a clearphotocopy
of
the LD., and the applicant's signature signed in front
of
a notary
public
or
in
the presence
of
an
Iowa Registrar
of
Vital Records.
PA
YMENT: A
non-refundable
$15 fee is
required
to
search
for a record and includes one certified copy
if
the
record is located. Each additional copy
of
the same record is
$15.
Fees are payable in U.S. funds
by
check
or
money
order to the issuing registrar's office. Checks must be drawn from the applicants' account; money orders
must
be
in
the
name
of
the applicant. Fees must be paid at the time
of
the application (Iowa Constitution, Article VII, Section 1).
STATE
CERTIFIED COPIES.
Certified copies
of
birth, death,
or
marriage certificates may be obtained from the state Bureau
of
Health Statistics by
telephone, in-person,
or
through a postal service. Fees are payable in u.s. funds
by
check
or
money order to the Iowa
Department
of
Public Health. In-person requests may also be paid
in
cash. Genealogy requests take
at
least 60 days.
Telephone:
For
general information, or to order a certified copy by telephone using a credit card, call 515-281-4944
from 7:00 a.m. to 4:45 p.m., Monday through Friday, except for state-observed holidays.
An
additional $5.50 fee is
charged for the expedited process
of
credit card usage. Turnaround time is usually
10
to
14
days, depending
on
seasonal
demands and mail service.
Genealogy requests are
not
available through the credit cardline.
In-person:
Applications
may
be
made in-person at the state Bureau
of
Health Statistics 7:00 a.m. to 5:00 p.m., Monday
through Friday, except for state-observed holidays,
at
the address below,
just
inside the north lobby entrance and to the
right. The Lucas building is
just
east
of
the state Capitol and south
of
Grand Avenue. Applicants must provide current
government-issued photo identification and sign their request in the presence
of
registrar staff. Copies
may
either be
picked up after two
working
days
or
mailed to
an
entitled person. Genealogy requests take
at
least 60 days.
Postal
service:
Written requests and fees are mailed to the address below. Requests must state the relationship to the
person named
on
the record and the purpose for the copy. Filled requests take
30-45
days, depending
on
seasonal
demands and mail service. Genealogy requests take least 60 days.
The request
must
be signed in front
Q[
!!
notary
public
and
include!! clear photocopv
!!fthe
applicant's current government-issued photo identification.
Iowa Department
of
Public Health
Bureau
of
Health Statistics
Lucas State Office Building, 1
st
Floor
321
E.
12
th
Street
Des
Moines, Iowa 50319-0075
SEE OTHER SIDE FOR AN APPLICATION FORM.
FORM
MAY
BE
USED FOR EITHER A COUNTY-CERTIFIED OR A STATE-CERTIFIED COPY OF AN
IOWA
VITAL RECORD
588.Q225VR
(January
1.
2005
-fee
Increase
to
$15)
UPDATE
d
FEBRUARY
15.
2006
PLEASE SEND TO: PLYMOUTH COUNTY RECORDER, 215 4TH AVE SE Le Mars, IA 51031
PLEASE SEND TO: PLYMOUTH COUNTY RECORDER, 215 4TH AVE SE LE MARS, IA 51031
