NEW YORK STATE DEPARTMENT OF HEALTH
VITAL RECORDS SECTION
Application to Local Registrar
for Copy of Death Record
Fee: County District - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
Identification Requirements: Application must be submitted with copies of either A or B.
(Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.)
A. One (1) of the following forms of valid photo-ID:
•
Driver license
•
Non-driver photo-ID card
•
Passport
•
U.S. Military photo-ID
Name of Deceased: Social Security No. of Deceased:
First Middle Last
Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death:
From To
Maiden Name of Mother of Deceased:
mm / dd / yyyy
Death Certificate No.: (If known)
First Middle Maiden Last
Name of Father of Deceased:
Local Registration No.: (If known)
First Middle Last
Place of Death:
Name of Hospital or Street Address Village, town or city County
Number of Copies Requested:
(For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.)
Copies requested
with
confidential cause of death
Copies requested
without
confidential cause of death
Total number of
copies requested
Purpose for which Record is Required:
What is your relationship to person whose record is required?
In what capacity are you acting?
If attorney, give name and relationship of your client to person whose record is required:
If you are not the parent or child of the deceased or the spouse of the deceased
at the time of death, you must submit documentation of a lawful right or claim.
Signature of Applicant:
Date Signed:
Month Day
Year
Type of ID:
FOR REGISTRAR'S USE ONLY
(Photocopy ID and attach to application form)
Address of Applicant:
(Applicant's Name)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
DOH-294A (06/2005)
Driver License
Issuing state:
Expiration date:
Number:
Other ID, Specify
Number:
Type:
Number:
Type:
Mail completed form to:
The Town of North Hempstead
200 Plandome Road
Manhasset, NY 11030
Attn: Office of the Registrar
The Town of North Hempstead
Office of the Registrar
Money Order Payable to Town of North Hempstead
Obtaining a Copy of a Death Record
There are three (3) types of death documents permitted for issue by NYS Public Health
Law.
They are:
□
Certified Copy A photographic reproduction of the actual death certificate
Certified
Transcript
A computer- generated or other reproduction of information
abstracted from the actual death certificate
□
Certification
A computer- generated or other reproduction of only the name
of the person to whom the death relates, the date, place of
death, and the filing date.
A Certified Copy or Certified Transcript of death can be issued to the spouse, parent
or child of the deceased; to a lawful representative of the spouse, parent or child of the
deceased; to a person requiring the record for legal right or claim; documented medical
need, by NYS Court order or to a government agency when needed for an official
purpose.
A Certification of death can be issued to the spouse, parent or child of the deceased;
to a lawful representative of the spouse, parent or child of the deceased if and when
there is only need for documentation of death.
Forward Mail Requests To:
Registrar - Town of North Hempstead
200 Plandome Road P. O. Box 3000
Manhasset, New York 11030
Include a Stamped, Self-addressed envelope with:
1. A $10 Money Order for each copy ordered.
2. A Photo copy of the requestor’s Identification. (State Motor Vehicle
Driver’s license, Non-Driver I D, Passport or other birth related I D)
3. Give name, date or death, relationship to the decedent and reason
the death record is being requested.
Priority Handling
* In addition to the requirements above: Send request via FEDEX, USPS,
UPS or other overnight carrier and include a pre-paid, self-addressed
return envelope and applicable pick-up charges. (Example, UPS charges
6.95 for pick-up of all pre-paid envelops & packages)
DOH-294A (06/2005) - instructions
□
