Application to Local Registrar for Copy of Death Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Death Record
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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
Name of Father of Deceased
Last
Social Security Number of Deceased
First Middle
Maiden Name of Mother of Deceased
Last
Date of Birth of Deceased
Age at Death
First
Place of Death
Middle
Last
Month
Da
Year
Name of Hos ital or Street Address
Purpose for Which Record is Required
Villa e, Town or Ci
Coun
What was your relationship to the deceased?
In what capacity are you acting?
If attorney, name and relationship of your client to deceased
Signature of Applicant
Address of Applicant
Date
_ Number of copies requested with confidential cause of death
_ Number of copies requested without confidential cause of death
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Name
Address
City
State
Zip Code
DOH-294A (6/2000)