ARKANSAS…

                                                        ARKANSAS DEPARTMENT OF HEALTH
                                                             Vital Records Section H-44
Date                                                                     4815 West Markham
                                                                         Little Rock, AR 72205
                            BIRTH CERTIFICATE RESULTING IN STILLBIRTH APPLICATION
    Only Arkansas births are recorded in this office. There are only a limited number of birth records filed in this office prior to February 1, 1914. The fee is
    $12.00 for the first copy ordered and $10.00 for each additional copy of the same record. The fee must accompany the application. Send check or
    money order payable to the Arkansas Department of Health. DO NOT SEND CASH. Of the total fee you send $12.00 will be kept to cover search
    charges if no record of the birth is found. Only the names and dates listed will be searched for the $12.00 fee. Names and other dates submitted later
    will require an additional $12.00 non-refundable fee. Mail this application and the money to the address above. Please allow 4-6 weeks for processing
    mail requests.
    List Below All Possible Birth dates and Names Under Which the Certificate May be Registered                               (Type or Print)
                              First Name                      Middle Name                                                   Last Name
1     Full Name at
      Birth
                              Month                                Day                    Year                     Sex         Race
2     Date of Birth

                              City or Town                                 County                               State                      Order Of This Birth
                                                                                                                                           (1st, 2nd, 3rd, etc.)
3.     Place of Birth
                              Name of Hospital or Street Address                                                            Name of Attendant at Birth


                              First Name                           Middle Name                                              Last Name
4.     Full Name of
       Father
5. Full Maiden Name           First Name                           Middle Name                                              Last Name
  of Mother (Name
  Before Marriage)

                                                                                                                         DO NOT WRITE IN THIS SPACE
                                                                                                             Name of Searcher
      If you have received a copy before, please give certificate #

      What is your relationship to the person whose certificate is being                                     Index
      requested?
      What is your reason for requesting this certificate?                                                   Delayed                            Prior

      Signature and telephone number of person requesting this certificate.                                  Volume Number

                                                                                                             Page Number                      Year


Certificates may also be ordered by the following methods:
Internet: www.expressvitalrecords.com or www.vitalchek.com The service fee and the
certificate fee are charged to your credit card. (Visa, Master Card, Discover or American
Express). Certificates may be sent by overnight courier for the cost of the additional shipment              HOW MANY COPIES?
f
                                                OR
Telephone: Toll free (888) 803-1118 or (866) 209-9482) The service fee and the certificate
fee are charged to your credit card. (Visa, Master Card, Discover or American Express).
Certificates may be sent by overnight courier for the cost of the additional shipment fee.
                                                                                                             The 1st copy costs $12.00
                                                  OR                                                         Each additional copy costs $10.00

Walk-in: You may order a certified copy of the record by coming into this office. Orders                     AMOUNT OF MONEY ENCLOSED $
are accepted for same day issuance from 8:00 A.M. until 3:00 P.M. Monday through Friday.
The office is located at 4815 West Markham St. Little Rock, AR 72205. Please order family
history and genealogy by mail or Internet

Please PRINT below the name and address of the
person who is to receive the copy(ies) or cards


                                                                               Any person who willfully and knowingly makes any false statement in an application for a
                                                                              certified copy of a vital record filed in this state is subject to a fine of not more than ten
                                                                              thousand dollars ($10,000) or imprisoned not more than five (5) years, or both
                                                                              (Arkansas Statutes 20-18-105).



VR-7b (8/07)