Report of Lost or Stolen Certificate Form 1 2016 .pdf

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Original filename: Report-of-Lost-or-Stolen-Certificate-Form-1-2016.pdf
Title: December 23, 2008
Author: Barnhart Communications

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Thomas Forslund, Director

Governor Matthew H. Mead

(Only for birth’s occurring in Wyoming)

This form cannot be used for requesting a birth certificate
Name, address, and phone number of person completing this form:
Full Name: _________________________________________________________________
Phone: ____________________________________________________________________
Address: ___________________________________________________________________
City, State, Zip: ______________________________________________________________
Information on the birth certificate that is missing or stolen:
Full Name on Certificate: ______________________________________________________
Date of Birth: _____________ City or County of Birth in Wyoming _______________________
Mother’s Full Maiden Name: ____________________________________________________
About what date was the certificate missing or stolen: ________________________________
Please write a brief statement about what happened to the birth certificate:

Signed: ____________________________________ Date: _________________
Notice: In an effort to protect the Registrant from Identify Theft, records associated with lost or stolen birth certificates are
flagged. Information may be shared with appropriate law enforcement agencies in an effort to protect the people of Wyoming
from the threat of Identity Theft.

Return this form to:
Vital Records Services
Hathaway Building
Cheyenne, WY 82002

Wyoming Department of Health • Vital Statistics Services
E-Mail: • WEB Page:
Main Number (307) 777-7264 • FAX (307) 777-2483
WDH_VSS Report of Lost or Stolen Certificate Form 1 2016

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