Report of Voided Certification of Death Forms
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Report of Voided
Certification of Death Forms
District Number Year
District Name Page
of
1. Record the serial press number assigned to each voided Certification of Death (VS-58) on this report.
2. Destroy voided Certifications of Death in a confidential manner. Do Not Return Voided Forms to the Vital
Records Section.
3. Maintain this report as a permanent record.
4. Annually submit a copy of this report to the Vital Records Section by January 31 st of the year following the year
in which the listed forms were vOided and destroyed.
I verify that the above listed Certification(s) of Death (VS-58) have been destroyed.
Name of Local Registrar (Print)
Signature
Date
DOH-2823 (12/89)