Notification of Appointment of Registrar of Vital Statistics
Registration Unit
Vital Records Section - P O. Box 2602, Albany, NY 12220-2602
Notification of Appointment of
Re istrar of Vital Statistics
IMPORTANT This notice and oath shall be executed in triplicate immediately after appointment of the registrar and deputy
registrar. File original copy with the New York State Department of Health, file one copy with your County Clerk
and retain one copy for your records.
Current Appointee New Appointee
(If reappointment, enter correction onlv)
COUNTY & DISTRICT NUMBER
REGISTRAR Name
Town/CityNillage
Street Address
City and State
Zip Code
Telephone Number ( ) Ext ( ) Ext
(include area code & ext)
E-Mail Address
o Reappointment 0 New Appointment
If New Appointment, is this 0 Election 0 Resignation 0 Other
Effective Date of Appointment I I
(give month and year) ..
If City/TownNillage Clerk 0 Yes 0 No Specify Locality
Length of Term
(give number of years)
Date Term Expires
(aive month and \tear)
FAX (
Salaried 0 Yes
ONo
Signature of Appointing Officer
Business Address
Telephone
it e 0 ApPolntlnQ Icer ate
DEPUTY Name
REGISTRAR Street Address
City, State and Zip Code
Telephone Number ( ) Ext ( ) Ext
(include area code & ext)
D
TI
Offi
STATE OF NEW YORK
COUNTY OF
)
) ss
REGISTRAR'S AFFIDAVIT
I do solemnly swear (affirm) that I will support the Constitution of the United States,
and the Constitution of the State of New York, and that I will faithfully discharge the
duties of the office of Registrar of Vital Statistics, according to the best of my abilities.
I am not engaged in the business of funeral directing, embalming or undertaking.
Signed
Home Address
Telephone
Registrar of Vital Statistics
Subscribed and sworn to
(affirmed) before me this day of
STATE OF NEW YORK )
COUNTY OF ) ss
Notary Public
DEPUTY REGISTRAR'S AFFIDAVIT
I do solemnly swear (affirm) that I will support the Constitution of the United States,
and the Constitution of the State of New York, and that I will faithfully discharge the
duties of the office of Deputy Registrar of Vital Statistics, according to the best of
my abilities
I am not engaged in the business of funeral directing, embalming or undertaking.
Signed:
Home Address
Telephone
Deputy Registrar of Vital Statistics
Subscribed and sworn to
(affirmed) before me this day of
Notary Public
DOH-1556 (11/2001)