Application to Local Registrar for Copy of Birth Record
NEWVORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Reg istrar
for Coey of Birth Record
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D Passport
D Social Security-Retirement
D Social Security-SSI
D Retirement
D Employment
D Other (Specify)
First
Middle
Last
Name
Hospital (If not hospital, give street & number)
Place of
Birth
First
Middle
Last
Father
Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
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NAME
What is your relationship to person whose
record is required?
o Self 0 Parent 0 Other, specify
Telephone No. (WJ) WJ-LillJ
Social Security No. LLlJ-W-UlJJ
Signature of Applicant
Date
WW
MM DO YY
Address of Applicant
Street
City
State
Zip Code
DOH-296A (11 /94 ) Page 1 of 2
Date of Birth LU W LLLU
MMDDVVVV
(Village, Town or City) County
Maiden Name
of Mother
First
Middle
Last
Enter Local Registration
No. if Known
D Working Papers
D School Entrance
D Driver's Ucense
D Marriage Ucense
D Welfare Assistance
D Veteran's Benefits
D Court Proceeding
D Entrance into Armed
Forces
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If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
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TYPES OF ACCEPTABLE IDENTIFICATION
1. Driver's license
2. Non-driver's license
3. Passport
4. Naturalization Papers
5. Military ID
6. Employer's Photo ID
7. Two utility bills, showing applicant's name and address
8. Police report of lost or stolen ID
DO NOT ISSUE COPY UNLESS ONE OF THE ABOVE TYPES OF IDENTIFICATION
IS PRESENTED
DOH-296A (11/94) Page 2 of 2