Application For Certified Copy Of Birth Certificate - Elmira, Ny printable pdf download

CHEMUNG COUNTY VITAL STATISTICS - 103 WASHINGTON STREET

PO BOX 588 - ELMIRA, NY 14901 -

PHONE: 607-737-2018- FAX: 607-737-0437

Application for Certified Copy of Birth Certificate

Certificate information:

____________________

________________________________________________________

Date of Birth

Town, city or village where birth occurred

(Must be in Chemung County

or your request cannot be processed through this office.)

M / F

Print Name

First

Middle

Last

Sex (circle 1)

If married give maiden name, adoptees use name given at adoption and names of adopting parents.

Was individual adopted: (circle one) Yes No

_____________________________________

______________________________________

Full Maiden Name of Mother

Fathers name (If not listed state not listed)

Purpose for which records is required: _________________________________________

Number of copies requested: _______ Certificate fees: $15.00 one copy + $10.00 each additional copy of the

Expedited orders will be charged an additional $40 (Standard

same record ordered at the same time.

Overnight service.) Saturday delivery is not available and we cannot guarantee overnight carrier’s

services.

Acceptable forms of payment: Money orders or certified checks made payable to Chemung County Vital

Records. No personal checks. Payments made by Credit or Debit will be charged a minimum

service/convenience fee of $3.00 or up to 2.45% of the total sale. Do not send cash through the mail.

If information is incomplete, payment isn’t enclosed or Credit/Debit is denied, your request

will not be processed.

**** Fees are not refundable****

_____________________________________

_______________________ _____________

CREDIT/DEBIT CARD #

EXPIRATION DATE

3 DIGIT SECURITY CODE

_________________________________________________________________________

Name as it appears on Credit/Debit card. (Cardholder must be applicant or provide a notarized

consent form the cardholder, see Forms.)

___________________________________

__________________________________________

Mailing address (If paying with credit/debit,

Physical address

this address must match credit/debit billing address)

Name of Applicant: _____________________________________Relationship:___________

(Please print)

(If self indicate self)

Contact phone#:__________________________

Signature:_______________________________________________ Date:_______________

(Signature must be notarized if using

or if you do not have photo identification with current

PO BOX

mailing address listed.) PLEASE INCLUDE A SASE WITH YOUR REQUEST.

__________________________________

Notary Signature & date

Notary stamp:

Application For Certified Copy Of Birth Certificate - Elmira, Ny

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