Vital Records Section
Application to Local Registrar
for Copy of Birth Record
Name: (as listed on birth certificate) Date of Birth:
First Middle Last
(mm / dd / yyyy)
Town, city or village where birth occurred: Name of hospital where birth occurred: (If known)
Maiden Name of Mother: (as listed on birth certificate)
Local Registration No.:
(If known)
Father: (as listed on birth certificate)
Number of Copies
Purpose for which
Record is Required:
(Check one)
Social Security
Other (specify)
Working Papers
School entrance
Driver license
Marriage license
Welfare assistance
Veterans benefits
Court proceeding
Entrance into
Armed Forces
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:
Date Signed:
Signature of Applicant:
Address of Applicant:
(Applicants Name)
(City) (State) (Zip)
Telephone No.: ( )
DOH-296A (06/2005)
A. One (1) of the following forms of valid photo-ID:
 Utility or telephone bills
Two (2) of the following showing the applicants name
and address:
Letter from a government agency dated within the
last six (6) months
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.)
 Driver license
 Non-driver photo-ID card
 Passport
U.S. military issued photo-ID
(Photocopy ID and attach to application form)
Type of ID:
Other ID, Specify
Issuing state:
Expiration date:
Driver License
First Middle Maiden Last
First Middle Last
Obtaining a Copy of a Birth Record
There are three (3) types of birth documents permitted for issue by NYS Public Health
They are:
Certified Copy
A photographic reproduction of the actual birth certificate
A computer- generated or other reproduction of information
abstracted from the actual birth certificate
A computer- generated or other reproduction of only the name
of the person to whom the birth relates, the date, place of birth,
and the filing date.
A Certified Copy or Certified Transcript of birth can be issued to the person on the
birth record if eighteen years of age or older, to his/ her parents, a lawful representative
or lawful representative of his/ her parents or by NYS Court order.
A Certification of birth can be obtained by the person under 18 years of age if named
on the birth record or by a person who can demonstrate that the record is required for a
judicial or other proper purpose.
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 birth, name of parents including
mother's maiden name of the person for whom the birth record is being
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 envelop and applicable pick-up charges. (Example, UPS charges $
6.95 for pick-up of all pre-paid envelops & packages)
DOH-296A (06/2005) - instructions