Form Doh-3667 - Application To Department Of Health For Copy Of Fetal Death Record - New York State Department Of Health Vital Records Section

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Application to Department of Health
for Copy of Fetal Death Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
PLEASE COMPLETE FORM AND ENCLOSE FEE
Initial copy or No Record Certification is free. Additional copies are $30.00 each. Make money order or
FEE:
check payable to New York State Department of Health. Please do not send cash or stamps. Return
with required fee to: Certification Unit, Vital Records Section, P.O. Box 2602, Albany, NY 12220-2602.
PLEASE PRINT OR TYPE
Maiden Name of Patient
First
Middle
Last
Address
Street Address
Village, Town or City
Zip Code
Patient's Date of Birth
Social Security Number of Patient (last 4 digits only)
Month
Day
Year
Name of Facility
Street Address
Village, Town or City
Zip Code
Certifying Doctor's Name
Name of Funeral Director - Check box if none
Street Address
Village, Town or City
Zip Code
Date of Fetal Death
Date of Disposition
Month
Day
Year
Month
Day
Year
Name of Fetus - Check box if a name was not entered on the Fetal Death Certificate
First
Middle
Last
Name of Father - Check box if a name was not entered on the Fetal Death Certificate
First
Middle
Last
Sworn to Before me this
Day of
,
Signed
(Patient)
(Notary Public)
NOTE: Signature must be notarized.
PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT
(
)
Name
Telephone
Address
City
State
Zip Code
DOH-3667 (06/2003)

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