Form Doh-296b - Application For Copy Of Birth Record
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1Application for Copy of
N
Y
S
D
H
EW
ORK
TATE
EPARTMENT OF
EALTH
Vital Records Section
Birth Record
PLEASE COMPLETE FORM AND ENCLOSE FEE
FEE: $15.00 per copy or No Record Certification.
Make money order or check payable to New York State Department of Health. Please do not send cash or stamps.
Send to:
New York State Department of Health
Vital Records Section
Empire State Plaza
Albany, NY 12237-0223
PLEASE PRINT OR TYPE
Name:
Date of Birth or Period Covered by Search:
First
Middle
Last
Place of Birth:
Village, town or city
County
Hospital (if not hospital, give street & number)
Father:
Maiden Name of Mother:
First
Middle
Last
First
Middle
Last
Number of Copies Requested:
Birth Certificate No. If Known ____________
Standard Size _______
Wallet Size_______
Local Registration No. If Known _______________
Purpose for which
Passport
Working papers
Welfare assistance
Record is Required
Social Security
School entrance
Veteran’s benefits
(Check one)
Retirement
Driver’s license
Court proceeding
Employment
Marriage license
Entrance into Armed Forces
Other (specify) ________________________________________________________
What is your relationship to person whose record is
If attorney, given name and relationship of your client to
required? If self, state “self”.
person whose record is required.
This office requires written authorization of the person/parents whose record is requested before processing.
Signature of Applicant:
Date (mm/dd/yy):
Address of Applicant:
Please print name and address where record should be sent:
__________________________________________
________________________________________________
(street)
(name)
__________________________________________
________________________________________________
(city)
(state)
(zip)
(street)
_____________________________________________
(city)
(state)
(zip)
DOH-296B (4/96)
eSecret.net Fill in Forms. This Box Does Not Print.
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