Fillable OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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THE CITY OF NEW YORK – DEPARTMENT OF HEALTH AND MENTAL HYGIENE
OFFICE OF VITAL RECORDS
125 Worth Street, CN 4, Room 133
New York, N.Y. 10013-4090
SIGN / PRINT YOUR NAME AND RECORD YOUR ADDRESS BELOW
SIGNATURE PRINT NAME
STREET ADDRESS
CITY
DAYTIME TELEPHONE NUMBER
STATE
APT. NO.
ZIP CODE
FEES
SEARCH FOR TWO CONSECUTIVE YEARS AND ONE COPY, OR A CERTIFIED “NOT FOUND STATEMENT” $15.00
EACH ADDITIONAL COPY REQUESTED $15.00
EACH EXTRA YEAR SEARCHED (WITH THIS APPLICATION) $ 3.00
1. Make check or money order payable to: N.Y.C. Department of Health and Mental Hygiene. CASH NOT ACCEPTED BY MAIL.
2. If from a foreign country, send an international money order or check drawn on a U.S. Bank.
VR 67 (REV. 8/02)
Area Code Telephone Number
NOTE: PLEASE ATTACH A STAMPED, SELF-ADDRESSED ENVELOPE
1. LAST NAME ON BIRTH RECORD
4. DATE OF BIRTH
Month Day Year
2. FIRST NAME
12. FOR WHAT PURPOSE ARE YOU GOING TO USE THIS BIRTH RECORD
6. BOROUGH OF BIRTH
5. PLACE OF BIRTH (NAME OF HOSPITAL, OR IF AT HOME, NO. AND STREET)
10. NO. OF COPIES
11. YOUR RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD
IF SELF, STATE “SELF”
9. FATHER'S NAME
FIRST LAST
7. MOTHER'S MAIDEN NAME (NAME BEFORE MARRIAGE)
FIRST LAST
3. ❏ FEMALE
❏ MALE
8. CERTIFICATE NUMBER (IF KNOWN)
(FOR OFFICE USE ONLY)
NOTE: Copy of a birth record can be issued only to persons to whom the record of birth relates, if of age, or a parent or other lawful representative.
IF THIS REQUEST IS NOT FOR YOUR OWN BIRTH RECORD OR THAT OF YOUR CHILD, NOTARIZED AUTHORIZATION FROM THE PARENT
OR THE PERSON NAMED ON THE CERTIFICATE MUST BE PRESENTED WITH THIS APPLICATION.
Section 3.19, New York City Health Code provides, in part: “. . .no person shall make a false, untrue or misleading statement or forge the
signature of another on a certificate, application, registration, report or other document required to be prepared pursuant to this Code.”
Section 558 (e) of the New York City Charter provides that any violation of the Health Code shall be treated and punished as a misdemeanor.
APPLICATION FOR A BIRTH RECORD
(Print All Items Clearly)
SEE IDENTIFICATION REQUIREMENTS ON REVERSE
Valid Photo-Identification Defined: Identification (ID) with a photograph of the bearer that has the signature of the
bearer. ID must be issued by an officially recognized organization or agency and includes the following types of ID:
Driver’s License, Employment ID, Government ID, Social Services ID, and a Passport.
VR 67 (REV. 8/02)
For Yourself or Your Child:
䊳 Valid photo-ID, OR
䊳 Inmate photo-ID with Release
Papers, OR
䊳 Two of the following showing
your name and address:
Utility/Telephone Bills
Letter from Government Agency
WITHOUT VALID PHOTO–ID,
CERTIFICATE WILL BE MAILED
䊳 Your valid photo-ID, AND
䊳 Other person’s valid photo-ID, AND
䊳 An original, notarized letter
from the person authorizing his or her
certificate’s release to you.
Walk-in Customers
䊳 Copy of valid photo-ID, OR
䊳 Two of the following showing
your name and address:
Utility/Telephone Bills
Letter from Government Agency
䊳 A copy of your valid photo-ID, AND
䊳 A copy of the other persons photo-ID,
AND
䊳 An original, notarized letter from the
person authorizing their certificate’s
release to you.
Mail-in Requests
䊳 Valid Credit Card
䊳 Identification verified by Health
Department computer system
Save Time!
WEB SITE: www.nyc.gov
MAIL YOUR APPLICATION TO:
NYC Department of Health and Mental Hygiene
Office of Vital Records
125 Worth St., CN 4, Rm. 133
New York, N.Y. 10013-4090 OR
FAX TO (FOR CREDIT CARD ORDERING ONLY):
1 (212) 962-6105 if calling from 5 boros, NYC OR
1 (800) 908-9146 if calling from outside NYC
PHONE: 1 (212) 788-4520 for Credit Card Service OR
WALK-IN: When the lines are shortest
from 9–10 AM or 3–4:30 PM
The following fees apply:
Certificates – $15.00
Credit Card Handling – $5.50
Express Mailing Service for Credit Card Orders – $12.50
Credit Card Orders
By telephone including
form filler automated service
For yourself or your child only
䊳 Valid Credit Card
verified by Health Department
computer system
Faxed Requests
For yourself or your child only
Someone other than Self/Child:
Birth Certificate Identification Requirements
Official Agency Letter Defined: Without valid, signed photo-identification you must obtain a letter from an official
agency such as the police department or a social services office on their letterhead, which confirms your exceptional
situation. Additional criteria are described below.
Requirements for those with exceptional situations who are unable to
meet Birth Identification Criteria: Issuance criteria
for yourself and your child ONLY
Without valid Photo-ID, your certificate will be mailed to you
䊳 Official Agency Letter, AND
䊳 One of the following showing your name and address: A Utility Bill, a Telephone
Bill, or a Letter from a Government Agency, i.e., A Social Security award letter, OR
䊳 A notarized letter from your landlord that verifies your name and residence, WITH
a Telephone or Utility Bill showing the Landlord’s name and address.
Walk-in Customers
Mail-in Requests
Faxed Requests
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OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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Completed 25 July 2021

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