New York State Department of Health						Application to Local Registrar
Vital Statistics Section						for Copy of Birth Record
			CERTIFICATE INFORMATION
	First	Middle	Last
					Date of Birth
Name						MM	DD	YYYY
	Hospital (If not hopsital, give street & number)				(Village, Town or City)				(County)
Place of
Birth
	First	Middle	Last			First	Middle	Last
Father					Maiden Name
					of Mother
Numer of Copies Requested			Enter Birth no. if Known			Enter Local Registration No. If Known
			Passport			Working Papers			Welfare Assistane
Purpose for Which			Social Security- Retirement			School Entrance			Veteran's Benefits
Record is Required			Social Security- SSI			Driver's License			Court Proceeding
(Check One)			Retirement			Marriage License			Entrance into
			Employment						Armed Forces
			Other (Specifiy)
			APPLICANT INFORMATION
	First	Middle	Last		If attorney, give name and relationship of your client to the
					person whose record is required.
Name
What is your relationship to the person whose
record is required?					Name of Client				Relationsip
	Self		Parent
	Other (specify)
						FOR REGISTRAR USE ONLY
Telephone No.							Photocopy ID and Attact to application form
Social Security No.					TYPE OF ID
Signature of Applicant							Driver's License
							State		No.
			Date				Other ID, specify
Address of Applicant							No.
	Street
City		State	Zip Code
Types of Acceptable Identification
1. Driver's License
2. Non-Driver's License
3. Passport
4. Naturalization Papers
5. Military ID
6. Empolyer's ID
7. Two utility bills showing applicants name and address
8. Police report of lost or stolen ID
DO NOT ISSUE COPY UNLESS ONE OF THE ABOVE TYPES OF IDENTIFCATION IS PRESENTED.