Name of Deceased: Social Security No. of Deceased:
First Middle Last
Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death:
mm / dd / yyyy
From To
Maiden Name of Mother of Deceased:
Death Certificate No.: (If known)
First Middle Maiden Last
Name of Father of Deceased:
Local Registration No.: (If known)
First Middle Last
Place of Death:
Name of Hospital or Street Address Village, town or city County
Purpose for which Record is Required:
What is your relationship to person whose record is required?
In what capacity are you acting?
If attorney, give name and relationship of your client to person whose record is required:
DOH-294A (06/2005)
If you are not the parent or child of the deceased or the spouse of the deceased
at the time of death, you must submit documentation of a lawful right or claim.
New York State Department of Health
Vital Records Section
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
-OR-
Number of Copies Requested:
Copies requested
confidential cause of death
Copies requested
confidential cause of death
Date Signed:
Signature of Applicant:
Address of Applicant:
(Applicants Name)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
FOR REGISTRARS USE ONLY
(Photocopy ID and attach to application form)
Type of ID:
Other ID, Specify
Number:
Type:
Number:
Type:
Issuing state:
Expiration date:
Number:
Driver License
Total number of
copies requested
Fee: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
