Physical Description Form
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
PHYSICAL DESCRIPTION FORM
LOCAL REGISTRAR: If an in-person request is made for a child whose birth certificate you
flagged upon notification from the New York State Department of Health
that such child was reported by the Division of Criminal Justice Services
as missing, each staff member who witnessed the requestor must
complete this form. A separate form should be used for the requestor
and each person appearing with the requestor. Complete as soon as
possible after the requestor leaves. Send a copy of this form to your
local law enforcement agency, the NYS Division of Criminal Justice
Services and the Vital Records Section.
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I . Child's Name
I
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............'..........................................................
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...-.............,..........................-.............................
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. . . . . . .. .......... . . . . . . . . .
Date of Birth
W
Month
W
Day
Vear
First
Middle
Last
Place of Birth
District No.
Father's Name
First
Middle
Last
Mother's Maiden Name
First
Middle
Last
Complete as much of the following Information as possible. REPORT DATE:
TIME:
This descriptIon concerns the:
D REQUESTOR 0 PERSON/CHILD WITH REQUESTOR
D Male
D Female
Name
Other Names Used
Approximate Age
Vears
Height
Ft. _ In. Weight
Lbs. Eye Color
Complexion 0 Ught
o Medium 0 Dark
Skin Color
Scars: C No Dves Shape
Size
Location
Tatoos: D No Dves Shape
Size
Location
DOH-3a96 (11/94) Page 1 of 2
Hair Color:
Style:
i Long
-----1
: Short
~ Wavy
~ Curly
H Crew Cut
I Bald
H Balding
tJ Other, Specify
Facial Hair:
,--,
~ Clean Shaven
W Beard
U Moustache
,,--,
H: ! Needs Shave
L Side Burns
Missing Teeth: D No eYes
Describe
Eyeglasses 0 No DYes
Style
Speaks with Accent: 0 No D Yes, Describe
Earrings: C No [] Yes n One ear I I Left ear i i Right ear
D Both ears
0 Shirt/Blouse Color D Long Sleeve I I Short Sleeve
D Pants Color D Long D Short
II n ,----,
L-J Dress/Skirt Color Long LJ Short
0 Coat/Jacket Color D Long D Short
i I Jewelry I I No D Yes, Describe
! i Other distinguishing charactenstics? D No I ! Yes, describe below:
Mode of transportation to your office (if known)
o Car D On Foot D Public Transportation 0 Other, specify
If car, Make
Model
Color
License No.
WITNESS INFORMATION
Name
First
Middle
Last
Phone # (
Signature
Date
DOH-389B (11/94) Page 2 of 2