Form Vr 67 - Birth Certificate Application - New York Office Of Vital Records
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1
2Office of Vital Records
125 Worth Street, CN-4, Room 133
New York, N.Y. 10013-4090
SEE INSTRUCTIONS AND
APPLICABLE FEES BELOW
AND ON BACK
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
BIRTH CERTIFICATE APPLICATION
(Please Print Clearly)
1. LAST NAME ON BIRTH CERTIFICATE
2. FIRST NAME
3.
FEMALE
MALE
4a. IF YOU KNOW THE EXACT DATE OF BIRTH
4b. IF YOU DON’T KNOW THE EXACT DATE OF BIRTH
SEE BELOW
BEGIN
END
FOR FEE
SEARCH
SEARCH
INFORMATION
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
5. NAME OF HOSPITAL OR ADDRESS WHERE BORN
6. BOROUGH WHERE BORN
7. MOTHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE (MAIDEN NAME):
8. BIRTH CERTIFICATE NUMBER (if known)
FIRST
LAST
9. FATHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE
10. WHY DO YOU NEED THIS BIRTH CERTIFICATE
FIRST
LAST
11. DO YOU NEED A LETTER
12. HOW MANY COPIES
13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE?
SELF/PARENT/OTHER (please explain)
OF EXEMPLIFICATION?
DO YOU NEED?
YES
NO
1
2
3
PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
NAME
DAYTIME
PHONE
NUMBER
Area Code
Telephone Number
STREET ADDRESS
APT. NO.
E-MAIL
CITY
STATE
ZIP CODE
ADDRESS
NOTE: Copy of a birth record can be issued only to persons to whom the record of birth relates, if of age, or to a parent or human
service organizations. It is a violation of law to make a false, untrue or misleading statement or forge the signature of another on this
application. Violations are a misdemeanor punishable by a fine of up to $2,000.
14. CUSTOMER SIGNATURE AND DATE
15. CUSTOMER COMMENTS/ADDITIONAL INFORMATION
SIGNATURE:
DATE:
NOTARY PUBLIC SEAL
APPLICATIONS SUBMITTED BY MAIL MUST
FEES
BE NOTARIZED
$15 per copy x _________ copies
$ ________
STATE OF
Cost of certified copy includes a two consecutive
year search
COUNTY OF
$3 for each extra year searched x ________ years $ ________
SUBSCRIBED AND SWORN BEFORE ME:
Total Amount Enclosed: $ ________
____
THIS ______ DAY OF _______________ , 20
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED.
CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.
NOTARY PUBLIC SIGNATURE
ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT
VR 67 (Rev. 01/14)
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