Application to Town Clerk
for Copy of Birth Certificate
TC-01 rev. 06/20
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-01 Page 2of 2
Applicants should mail the completed application to the Town Clerk for copy of Birth Certificate, along with proper identification.
Required ID must be included with application (see attached instructions for additional information or visit
www.brookhavenny.gov/departments/townclerk). No more than two (2) copies of a Birth Certificate will be issued within a 12-
month period. Make check or money order payable to Donna Lent, Brookhaven Town Clerk. Fee: $10 per copy or No Record
Certification. Please do not send cash or stamps. Enclose photocopy of required ID, self-addressed stamped envelope and fee.
CERTIFICATE INFORMATION
1. Name (as listed on Birth Certificate):
First Middle Last
2. Date of Birth
M M D D Y Y Y Y
3. Place of Birth: Hospital (if not hospital, give street and number)
4. Village, Town or City 5. County
6. Father/Parent’s Birth Name:
First Middle Last
8. Birth Certificate No.: (if known)
9. Local Registration No.: (if known)
7. Mother/Parent’s Birth Name:
First Middle Last
10. No. of Copies
Requested:
11. Amount Enclosed:
12. Purpose for which Record is Required: (Check One)
Passport Employment Driver’s License Veteran’s Benefit
Social Security Working Papers Marriage License Court Proceeding
Retirement School Entrance Welfare Assistance Entrance into Armed Forces
Other, Please Specify: ____________________________________
APPLICANT INFORMATION
13. Name:
First Middle Last
14. Telephone:
( )
15. What is your relationship to the person
whose record is required?:
(If self, state “SELF”)
16. If attorney, give name and relationship of your client to person whose record is
required:
Name of Client Relationship
17. Address of Applicant: 18. Name and Address Where Record Should Be Sent: (If delivery is to a
P.O. Box or third party, you must submit with this application a notarized
statement signed by the applicant stating such.)
19. Signature of Applicant: 20. Date:
This office requires written authorization of the person/parents whose record is requested.
TYPES OF ACCEPTABLE IDENTIFICATION:
1. Valid Driver’s License
2. Valid State-Issued Non-Driver’s License
3. Passport
4. Naturalization Papers
5.
Military ID
6. Employer’s Photo ID with Pay Stub
7. Two Utility Bills Showing Applicant’s Name and Address
8. Police Report of Lost or Stolen ID
FOR REGISTRAR USE ONLY
DO NOT ISSUE COPY UNLESS ONE OF TYPES OF ID IS
PRESENTED. Photocopy of ID and attach to application form.
Type of ID:
Driver’s License: State No.
Other ID, specify:
No.:
