Form Bc Web-20140729 - Application To Local Registrar For Copy Of Birth Certificate
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1Application to Local Registrar for Copy of Birth Certificate - by mail
CERTIFICATE INFORMATION
NAME AT BIRTH (FIRST, MIDDLE(FULL) AND LAST NAME):
DATE OF BIRTH
______/_____/_______
MM
DD
YYYY
PLACE OF BIRTH - HOSPITAL OR IF NOT HOSPITAL, STREET ADDRESS
VILLAGE
COUNTY
FATHER'S NAME (FIRST, MIDDLE AND LAST NAME):
MOTHER'S FULL MAIDEN NAME (FIRST, MIDDLE(FULL) AND LAST NAME):
NUMBER OF COPIES REQUESTED:
ENTER BIRTH NO. IF KNOWN
ENTER LOCAL REGISTRATION NO. IF KNOWN
Purpose for Which Record is Required (Check One)
Veteran’s Benefits
Passport
Working Papers
Court Proceeding
Social Security- Retirement
School Entrance
Entrance into Armed Forces
Social Security- SSI
Driver’s License
_____________
Other (Specify)
Retirement
Marriage License
Employment
Welfare Assistance
APPLICANT INFORMATION
(Copy of Certificate will be sent to the address listed below)
NAME (FIRST, MIDDLE AND LAST NAME):
WHAT IS YOUR RELATIONSHIP TO PERSON WHOSE RECORD IS REQUIRED?
Self
Parent
Other, specify _________
ADDRESS OF APPLICANT
___________________________________________
STREET
___________________________________________
CITY
STATE
ZIP CODE
TELEPHONE NO.
() -
__________________________ ____/____/______
SIGNATURE OF APPLICANT
DATE
Only the person themselves, their mother or father can request a copy.
FEE: $10.00 per copy
(money order payable to the Village of Port Chester)
Copy of your driver's license (or other photo ID)
Accepted forms of Identification
•
• Military ID*
Driver’s License
•
• Employer’s Photo ID*
Non-driver’s License
•
• Police report of lost or stolen ID*
Passport*
•
•
Naturalization Papers*
Two utility bills, showing applicant’s name and current address
*Must be accompanied by two pieces of official mail, showing applicant’s name and current address
Includes: utility bill(s), bank statement, and/or paystub
BIRTH CERTIFICATE WILL NOT BE ISSUED UNLESS ONE OF THE ABOVE TYPES OF IDENTIFICATION IS PRESENTED
Send with a self-addressed stamped envelope.
Please send request to:
Village of Port Chester - Vital Records
222 Grace Church St., Suite 120
Port Chester, NY 10573
BC WEB-20140729
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Parent category: Business