Application For Birth Certificate Template - Village Of Amityville
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2Village of Amityville
21 Ireland Place, Amityville, NY 11701, (631) 264-6000
APPLICATION FOR BIRTH CERTIFICATE
Name at Birth
Date of Birth:
First
Middle
Last
Place of Birth
Village, Town or City
Hospital (If not hospital, give street & number)
Father:
Maiden Name of Mother:
First
Middle
Last
First
Middle
Last
Number of Copies Requested:
Birth No. if Known
Local Registration No. if Known
□ Passport
□ Working Papers
□ Welfare Assistance
Purpose for which
□ Social Security-Retirement □ School Entrance
□ Veteran’s Benefits
Record is Required
□ Social Security-SSI
□ Driver’s License
□ Court Proceeding
(Check One)
□ Retirement
□ Marriage License
□ Entrance into Armed
□ Employment
Forces
□ Other (Specify)
APPLICANT INFORMATION:
NAME
If attorney, give name and relationship of your
client
person whose record is required.
First
Middle
Last
to
Email Address:
What is your relationship to person whose
(name of client)
(relationship)
record is required?
□ Self □ Parent □ Other, specify
FOR REGISTRAR’S USE ONLY
(Photocopy ID and attach to application form)
Telephone No.
TYPE OF ID:
□ Driver’s License
Signature of Applicant
Date
State
No.
Address of Applicant
□ Other ID, specify
City
State
Zip Code
No.
– did you:
MAIL INS
Complete and Sign the Application
Include Required Copy of Valid Photo ID
Do not send personal checks. Include a $10 per copy money order payable to the Village of Amityville. This fee
is a non-refundable processing fee in the event the Village does not have the Birth Certificate.
Include a stamped self-addressed envelope
“FREQUENTLY ASKED QUESTIONS” OR
FOR MORE INFORMATION VISIT
CALL (631) 264-6000 BETWEEN THE HOURS OF 8:00 AM AND 4:00 PM.
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