New York State Department of Health						Application to Local Registrar
Vital Statistics Section						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					Date of Death or Period to be Covered by Search
First		Middle		Last
Name of Father of Deceased					Social Security Number of Deceased
First		Middle		Last
Maiden Name of Mother of Deceased					Date of Birth of Deceased			Age at Death
First		Middle		Last	Month	Day	Year
Place of Death
Name of Hospital or Street Address					Village, Town or City				County
Purpose for Which Record is Required
What is your relationship to the deceased?
In what capacity are you acting?
If attorney, name and relationship of your client to deceased:
Signature of Applicant								Date
Address of Applicant
		COMPLETE FOR DEATHS OCCURRING AS OF JANUARY 1, 1988
	Number of copies requested with confidential cause of death
	Number of copies requested without confidential cause of death
	PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT
Name
Address
City					State		Zip Code
Types of Acceptable Identification
1. Driver's License
2. Non-Driver's License
3. Passport
4. Naturalization Papers
5. Military ID
6. Empolyer's ID
7. Two utility bills showing applicants name and address
8. Police report of lost or stolen ID
DO NOT ISSUE COPY UNLESS ONE OF THE ABOVE TYPES OF IDENTIFCATION IS PRESENTED.