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 Death Certificate
FEE: ONE (1) COPY $10.00 PER COPY
General Instructions
Use this application if you are the spouse, parent or child, or sibling of the deceased.
Use this application only if the death occurred in the Town of Islip.
Do not use this application for genealogy requests
Print a copy of this application, complete and sign.
Mail application with a money order and a copy of any required documentation or bring in person with cash or money
order and any required documentation (see below).
Identification requirements -Application MUST be submitted with copies of either A or B.
A. One (1) of the following forms of valid photo-ID:
State issued drivers or non-drivers license
Military ID
Passport
B. Two (2) of the following showing the applicant’s name and address:
Utility bills or telephone bills for two consecutive months
C. Applicant’s birth certificate must be provided
What is lawful right or claim?
If the applicant is not the spouse, parent or child (18 years or older), or sibling of the decedent, a lawful right or claim
must be documented. An example of lawful right or claim would be a death record needed by the applicant to claim a
benefit. Documentation would consist of a copy of a court order or an official letter verifying that a copy of the
requested death record is required from the applicant in order to process a claim.
Payment: If no record is on file, a No Record Certification is issued and the fee is not refunded. Mailed requests can only be
obtained by money orders. Completed requests will be returned by first class mail unless a pre-paid return mailer is provided. We
do not accept pre-paid envelopes from UPS. We will accept pre-paid envelopes from Federal Express or the Unites State Post Office
only.
Processing time: Mail requests will take up to two (2) to three (3) weeks once received.
Completing the Application: Once you have completed form, print and sign it. Bring or mail to Town of Islip Registrar Dept., 655
Main St., Islip, NY 11751 along with money order made payable to ‘Town of Islip” and any other required documentation. If you
bring in the application cash is accepted, but do not send cash through the mail.
Attorney copies: Requests must be made on letterhead. Please include all vital information and reason you are requesting same.
Attorney must sign letter and mail a copy of their driver’s license and Office of the Court Administration ID. Payment may be made
with your business check.
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
Application to Local Registrar for Copy of Death Record
Required ID must be included with application. Money order or check payable to the Town of Islip
FEE: $10.00 PER COPY
PLEASE PRINT OR TYPE
Name of Deceased
First Middle Last
Date of Death or Period to be
Covered by Search
Name of Father of Deceased
First Middle Last
Date of Birth of Deceased
Month Day Year
Maiden Name of Mother of Deceased
First Middle Last
Age at Death
Place of Death
Name of Hospital or Street Address Village Town or City County
What was your relationship to the deceased? ____________________________________________
In what capacity are you acting? ______________________________________________________
If attorney, name and relationship of your client to deceased ________________________________
Signature of Applicant ___________________________________ Date _______________________
Address of Applicant ________________________________________________________________
Telephone Number _________________________________________________________________
Number of copies requested
_____ with confidential cause of death
Number of copies requested
_____ without confidential cause of death
IF REQUESTED BY MAIL PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT
Name ___________________________________________________________________________
Address _________________________________________________________________________
City __________________________________ State ____________________ Zip Code ________
Funeral Home: ______________________________________________________________________
** FOR OFFICE USE ONLY** Copies: ____________________ Check or Money Order #.: __________________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome