No Record Certification - Death
STATE OF NEW YORK
Department of Health
No Record Certification. Death
District No.
THIS IS TO CERTIFY that a search has been made in this office for the death record
of
which death is said to have occurred on
(Date of Death)
at
, State of N ew York and that such record is not
(Place of Death)
on file in this office. Search has been made for the period from
Month
/
I
Day Year
to /
Month
I
/
Day Year
Witness my signature this
day of
19
Registrar of Vi tal Statistics
City }
To~n
Village of
DOH-3405 (3/93)
, New York
VS-63