NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application for Copy of
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:
Hospital (if not hospital, give street & number) Village, town or city County
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.
