NEW YORK STATE DEPARTMENT OF HEALTH for Copy of …
[Pages:1]Application to Local Registrar
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section any questions, please call (716)827-6431
for Copy of Death Record
PLEASE COMPLETE FORM AND ENCLOSE FEE
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Name of Deceased
PLEASE PRINT OR TYPE Date of Death or Period to be-covered by Search
First
Middle
Name of Father of Deceased
Last Social Security Number of Deceased
Flrst
Middle
Last
Maiden Name of Mother of Deceased
Date of Blrth of Deceased
Age at Death
First Place of Death
Middle
Last
Month
Day
Year
Name of Hospital or Street Address Purpose for Which Record IS Required
Village, Town or City
County
What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationshlp of your cliento deceased
Signature of Applicant Address of Applicant
Date
COMPLETE FOR DEATHS OCCURRFNG AS OF JANUARY 1,1988 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death
Name Address Clty
PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULDBE SENT
State
Zip Code
................
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