Application To Local Registrar For Copy Of Birth Record - Seneca Falls, Ny
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1Application to Local Registrar
OFFICE OF THE TOWN CLERK
For Copy of Birth Record
81 W. Bayard Street
Seneca Falls, NY
13148
Phone (315) 568-8013
SEARCH INFORMATION
First
Middle
Last
Date of Birth ___
___ ______
Name
MM
DD
YYYY
Village, Town or City
County
Hospital (If not hospital, give street & number)
Place of
Birth
First
Middle
Last
Mother’s
First
Middle
Last
Father’s
Maiden
Name
Name
Number of Copies Requested Enter Birth No. If Known
Enter Local Registration No. if Known
# __________
# __________
# __________
FEE: $10.00 per certified copy, $11.00 for genealogy – make check or money order payable to Seneca Falls Town
Clerk
__ Passport
__ Working Papers
__ Welfare Assistance
__ Social Security-Retirement
__ School Entrance
__ Veteran’s Benefits
Purpose for which
__ Social Security SSI
__ Driver’s License
__ Court Proceeding
Record is Required
__ Retirement
__ Marriage
__ Entrance into Armed
(Check one)
__ Employment
Forces
__ Other (specify) _______________________________________________________
APPLICANT INFORMATION
If attorney, give name and relationship of your client
Name_______________________________________
to person whose record is required
What is your relationship to the person whose record is
required?
____________________________ ______________
Name of Client
Relationship
__ Self __ Parent __ Other, specify ________________
Telephone No. (______) ______ - _________________
FOR REGISTRAR’S USE ONLY
Social Security No: _____________________________
TYPE OF ID
(Photocopy ID and attach to application form)
_____________________________________________
Signature of Applicant
Date
Driver’s License
___ ___ ____
__ State _____ No. ___________________
Address of Applicant
__ Other ID, specify
_____________________________________________
Street
________________________________
_____________________________________________
City
State
Zip Code
No. _____________________________
TYPES OF ACCEPTABLE IDENTIFICATION
1.
Driver’s License
5. Military ID
2.
Non-driver’s License
6. Employer’s Photo ID
3.
Passport
7. Two utility bills, showing applicant’s name and address
4.
Naturalization Papers
8. Police report of lost or stolen ID
WILL NOT ISSUE COPY UNLESS ONE OF THE ABOVE TYPES OF IDENTIFICATION IS PRESENTED
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