Application For Record Of Birth - Town Of New Hartford
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1
2APPLICATION FOR RECORD OF BIRTH
TOWN OF NEW HARTFORD
Gail Wolanin Young, CMC, Registrar
48 Genesee Street
New Hartford NY 13413
CHECK FORM DESIRED:
OFFICE USE ONLY:
(If none checked, short form will be issued.)
DOH 2248 __________________________
______ CERTIFICATION (8 ½” X 11” contains ONLY, name,
DOH 2673 __________________________
)
date and place of birth
Date Processed/Mailed _______________
______ TRANSCRIPT (8 ½” X 11” also includes parents’
names and time of birth)
By Whom __________________________
______ ACKNOWLEDGEMENT OF PATERNITY (LDSS4418)
First
Middle
Last
Sex
BIRTH
NAME
LOCAL REGISTRATION
DATE OF BIRTH
NO., IF KNOWN
HOSPITAL (if not hospital, give street and number)
PLACE
TOWN OF NEW HARTFORD
ONEIDA COUNTY
OF BIRTH
NOTE; A NO RECORD CERTIFICATION will be issues if upon our search, the desired record cannot be located (Fee: $10.00).
First
Middle
Last
FATHER’S NAME
(IF ON RECORD)
First
Middle
Last
MOTHER’S MAIDEN
NAME (Before Marriage)
PURPOSE FOR WHICH
Passport Social Security Veteran’s Benefits
RECORD IS REQUESTED
Welfare Retirement School Registration
Marriage Adoption Employment
Other (please specify) : ____________________________________________________________________
What is your relationship to person whose
record is required? If self, state “self” _________________________________________________________________
If attorney, give name and relationship of your
client to person whose record is required? _____________________________________________________________
Signature of Applicant
NOTE:
Your driver’s license must
NOTE: If child or parent is applying and their surname is different from when the birth record was registered,
be provided in order to have your
the child or parent must provide evidence of their surname change (i.e., marriage record, court order, etc.)
before we will process the application.
request processed.
Address of Applicant
(no PO Boxes, Business Addresses or c/o)
Phone No. (
)
Date
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