Application to Local Registrar
NEW YORK STATE DEPARTMENT OF HEALTH
for Copy of Birth Record
Vital Records Section
Fee: $10 per certified copy or No Record Certification
Identification Requirements: Application must be submitted with copies of either A or B.
(Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.)
-OR-
A. One (1) of the following forms of valid photo-ID
B. Two (2) of the following showing the applicants name
and address:
•
Driver license
•
Utility or telephone bills
•
Non-driver photo-ID card
•
Letter from a government agency dated within the
•
Passport
last six (6) months
•
U.S. military issued photo-ID
Name: (as listed on birth certificate)
Date of Birth:
First
Middle
Last
(mm/dd/yyyy)
Town, city or village where birth occurred:
Name of hospital where birth occurred: (If known)
Maiden Name of Mother: (as listed on birth certificate)
Local Registration No.:
First
Middle
Maiden Last
Father: (as listed on birth certificate)
Number of Copies
Requested:
First
Middle
Last
Purpose for which
Passport
Employment
Driver License
Veteran’s benefits
Record is Required:
Social Security
Working Papers
Marriage License
Court proceeding
(Check one)
Retirement
School Entrance
Welfare assistance
Entrance into Armed
Forces
Other (specify) ___________________________________________________________________
If request is not from child/parents named on the requested certificate, notarized authorization is required.
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”.)
Signature of Applicant:
Date Signed:
FOR REGISTRAR’S USE ONLY
Month
Day
Year
(Photocopy ID and attach to application form)
Type of ID:
Driver License
Address of Applicant:
Issuing state: ___________________________________________
Expiration Date: ________________________________________
Number: ______________________________________________
(Applicant’s Name)
Other ID, Specify
Number: ______________________________________________
(Street)
Type: _________________________________________________
Number: ______________________________________________
(City)
(State)
(Zip)
Type: _________________________________________________
Telephone No.: (
)
.