New York State Department of Health
Vital Records Section
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
Requested:
Purpose for which
Record is Required:
(Check one)
Passport
Social Security
Retirement
Other (specify)
Employment
Working Papers
School entrance
Driver license
Marriage license
Welfare assistance
Veterans 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:
(Applicants Name)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
DOH-296A (06/2005)
A. One (1) of the following forms of valid photo-ID:
B.
Utility or telephone bills
Two (2) of the following showing the applicants 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
Employment ID
FOR REGISTRARS USE ONLY
(Photocopy ID and attach to application form)
Type of ID:
-OR-
Other ID, Specify
Number:
Type:
Number:
Type:
Issuing state:
Expiration date:
Number:
Driver License
First Middle Maiden Last
First Middle Last
Fee: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
