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Notificationof Request for Missing Child's Birth Certificate
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section NOTIFICATION OF REQUEST FOR MISSING CHILD'S BIRTH CERTIFICATE LOCAL REGISTRAR: Send a copy of this form to your local law enforcement agency, the New York State Division of Criminal Justice Services and the New York State Department of Health, whenever a request is made for the flagged birth certificate of a missing child born in your district. . ...... ................. .................. ................. .................. ................. .................. ................. .................. ................. .................. ................. .................. ................. .................. .................. ................. .................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... '" ................... ............ .................... ......... ,................... ............. .................... ......,.. ......................... ................... .... ....................... ..................................... .................... ............ .............................................. .................... ::::::::..::]:.III~II":liM:IIII~i.!I~!I~i~:~j::ml~:w~:!:!: ....................... ...................... ....................... ....................... ........................ ....................... ..................... ............... . .......... ........ ....................... ....................... ....................... ....................... ....................... ....................... ....................... .................... ............................... . . . . . . . . . . . . . . . . . . . . . ........q................ ......................... .......................... ................ .. ........................ . . . . . . . . . . . . . . . . . . . . . . . . ........................ . . . . . . . . . . . . . . . . . . . . . . . . ........................ . . . . . . . . . . . . . . . . . . . . . . . . ........................ . . . . . . . . . . . . . . . . . . . . . . . . ........................ . . . . . . . . . . . . . . . . . . . . . . . . ........................ Child's Name Date of Birth LU LLJ LLLU First Middle Last MM DO yy Place of Birth District No. Father's Name First Middle Last Mother's Maiden Name First Middle Last Local Registrar No. State File No. DCJS No. .... . ...... .......................... ......................... . . . . . . . . . . . . . . ................... . ............... ....... ................................ ......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................. ....................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................. ....................... ............................ ........................ ............................. ....................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................. ............................. . ............ ............................. ........................ . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .................... ....................... ................... ........................ ....................... . .............. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... ........................... ....... .................. ....... ...................... .... ...... ....... ................... .... .. ..................... ....... .. ............... ... . ........... .................................. .. ...... .................. ............ . ............................ q........ ...................................... ..................................... ...................................... ..................................... ...................................... . . ........................ . . . . . . . . . . . . . . . . . . . Requestor's Name Date of Request LLJ W LLJ MM DO YY Request was made: D by mail, include copy of request or application o in-person, include copy of application form and physical description form(s) ... ..................... . . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . . . . . . . . . . . . . . ..................... ..................... ................... .............. .. .............. . ..................... .................... ......................... .............. . .................... ........................... ................... .............. ....... .................. .......................... .................. .. . ... ..... .. ...... ............................. .. ))::,:)))))))::.:::::II:I.IIIO;I~:I:::~I:E91111"11:::::::::::::::::::.::.: ..::. .j...,..:....::.:::.::::::.:::::::::::::::...:: ................. ................. ................. . . . . . . . . . . . . . . . . . ................. ................. ............. ....... ...................... ...................... ...................... .................. .................. .............................. ............................... .............................. ................... ... . Local Registrar Name Signature Telephone Date LOCAL REGISTRAR, SEND A COPY OF THIS FORM TO: 1) YOUR LOCAL LAW ENFORCEMENT AGENCY; 2) MISSING & EXPLOITED CHILDREN CLEARINGHOUSE NYS DIVISION OF CRIMINAL JUSTICE SERVICES EXECUTIVE PARK TOWER ALANY, NY 12203-3764 3) VITAL RECORDS DIRECTOR VITAL RECORDS SECTION NYS DEPARTMENT OF HEALTH P.O. Box 2602 Albany, NY 12220-2602 DOH -3895 (9/99)