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:
(If known)
First Middle Maiden Last
Name of Father of Deceased:
(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:
In what capacity are you acting?
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
U.S. Military photo-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: County District - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
