Form Doh-4380 - Mail-In Application For Copy Of Birth Certificate Page 2
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2NEW YORK STATE DEPARTMENT OF HEALTH
Mail-in Application for Copy of Birth Certificate
Vital Records Section
Required ID must be included with application. Make check or money order payable to New York State Department of Health.
For regular handling: Enclose $30 per copy or No Record Certification.
For priority handling: Enclose $45 per copy or No Record Certification.
Send to:
Submission by overnight carrier is recommended. Send to:
New York State Department of Health
New York State Department of Health
Vital Records Section / Certification Unit
Vital Records Section / Certification Unit
800 North Pearl Street - 2nd Floor
P.O. Box 2602
Menands, NY 12204
Albany, NY 12220-2602
Name: (as listed on birth certificate)
Date of Birth:
(mm / dd / yyyy)
First
Middle
Last
Town, city or village where birth occurred:
Name of hospital where birth occurred: (If known)
Maiden Name of Mother: (as listed on birth certificate)
Birth Certificate No.:
(If known)
Local Registration No.:
(If known)
First
Middle
Maiden Last
Father: (as listed on birth certificate)
Number of Copies Requested:
Standard Size:
Wallet Size:
First
Middle
Last
Purpose for which
Passport
Employment
Drivers license
Veterans benefits
Record is Required:
Social Security
Working Papers
Marriage license
Court proceeding
(Check one)
Retirement
School entrance
Welfare assistance
Entrance into
Other (specify)
Armed Forces
What is your relationship to person whose
If attorney, give name and relationship of your client to person whose record is required:
record is required? (If self, state "SELF".)
This office requires written authorization of the person/parents whose record is requested.
Date Signed:
Signature of Applicant:
Month
Day
Year
Regular Handling
$30.00 x
OR
(Check Only One)
Priority Handling
$45.00 x
Copies
=
$
Please print or type the name and address where record
should be sent:
Address of Applicant:
(If delivery is to a P.O. Box or third party, you must submit
with this application a notarized statement signed by the applicant and a copy of
the applicants drivers license.)
(Applicants Name)
(Name)
(Street)
(Street)
(City)
(State)
(Zip)
Telephone No.: (
)
(City)
(State)
(Zip)
DOH-4380 (12/05) Page 2 of 2
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