Revised 04/2015
TOWN OF ISLIP – ATTN: REGISTRAR’S OFFICE OLGA H. MURRAY
OFFICE OF THE TOWN CLERK TOWN CLERK & REGISTRAR OF VITAL STATISTICS
655 Main St., Islip NY 11751
townclerk@islipny.gov
631-224-5490
Information on How to Obtain a Birth Certificate
FEE: $10.00 PER COPY
A certified copy or transcript may be issued only to:
The parents of the person named on the birth certificate.
The person named on the birth certificate (only if 18 years of age or older).
A person with a New York State Court Order.
Lawful representative of the person named.
Acceptable Identification
State issued drivers or non-drivers license.
Military ID card.
Passport.
Police report, issued immediately preceding the application showing the requestor’s name and address.
Two current utility bills issued immediately preceding the application and, showing the requestor’s name and
address.
In the event that the applicant’s last name on the identification differs from the information on the certificate, a
copy of the applicant’s birth certificate, marriage certificate, and legal name changes paperwork must accompany.
If the applicant has a notarized authorization to obtain the record on behalf of an eligible individual, an original
notarized statement authorizing such, and ID from the eligible individual must accompany the request.
Fee: $10.00 per certified copy requested in cash, certified check, or money order made payable to "Town of Islip".
In-Person Request: The request may be accepted from a qualified applicant if the following conditions are satisfied:
Mail Request: A qualified applicant can complete a Copy of Birth Recordapplication and mail to the above address. An
application can be downloaded at http://www.islipny.gov/departments/town-clerk, or obtained at the Registrar’s Office,
655 Main Street, Islip, or by submitting a letter that provided the following information:
The applicant provides the name, date of birth, and place of birth of the named on the birth certificate. The father’s
first and last names and mother’s first and maiden names of the person named on the birth certificate.
The applicant provides his/her current name and address along with their relationship to the person named on the
birth certificate.
The request must be signed by the applicant.
A copy of an acceptable for of I.D. (see above).
$10.00 money order or certified check for each mailed request.
Revised 04/2015
OLGA H. MURRAY
TOWN CLERK & REGISTRAR OF VITAL STATISTICS
TOWN OF ISLIP – ATTN: REGISTRAR’S OFFICE
OFFICE OF THE TOWN CLERK
655 Main St., Islip NY 11751
townclerk@islipny.gov
631-224-5490
Local Registrar’s Application for Copy of Birth Record
Required ID must be included with application. Make money order or check payable to the Town of Islip.
Acknowledgement of Paternity _______ copies: No Charge Birth Certificate _______ copies: $10 each
Name: (as listed on Birth Certificate)
First Middle Last
Date of Birth:
(mm/dd/yyyy)
Town, City or Village where birth occurred:
Name of Hospital where birth occurred:
Father: (as listed on Birth Certificate)
First Middle Last
Mother: (as listed on Birth Certificate)
First Middle Last
Purpose for which record is being requested:
Passport
Social Security
Retirement
Employment
Working Papers
School Entrance
Driver’s License
Marriage License
Entrance into Armed Forces
Other (specify)
___________________________
What is your relationship to person whose
record is required? (If self, state “SELF”.)
If Attorney, give name and relationship of your client to person whose record is
required:
This office requires written authorization of the person/parents whose record is requested.
Address of Applicant:
____________________________________________
(Name)
____________________________________________
(Street)
____________________________________________
(City) (State/Zip)
____________________________________________
(Telephone Number)
Please print or type name and address where records 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 and a copy of the applicant’s Driver’s License.)
____________________________________________
(Name)
____________________________________________
(Street)
____________________________________________
(City) (State/Zip)
Signature of Applicant:
___________________________________
Date: _________________________________
(mm/dd/yyyy)
Registrar use only:
Receipt # ___________________
No Record
Cash
Mo# _______________________
Check # ____________________
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