2013NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
vital Records Section for Copy of Birth Record
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First Middle Last
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Name ~~~ ~~-~,r~c, uS~ e~ Date of Birt
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Hospital (If not hospital, give street & number) (Village, Town or City) County
Place of
Birth
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First Middle Last Maiden Name First Middle Last
Father
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Number of Copies Requested Enter Birth No. Enter Local Registration
if Known No. if Known
[~ Passport ^ Working Papers ^ Welfare Assistance
^ Social Security-Retirement ^ School Entrance ~] Veteran's Benefits
Purpose for Which ^ Social Security-SSI ^ Driver's License ~ Court Proceeding
Record is Required Retirement
^ ^ Entrance into Armed
^ Marriage License
(Check One)
^ Employment Forces
^ Other (Specify)
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NAME
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If attorney, give name and relationship of your
w~ r'al~l cr client to person whose record is required
What is your relationship to person whose
record is required?
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DOH-296A (11 /94) Page 1 of 2