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U.S.A. forms for Town of Brookhaven

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Application to Local Registrar
for Copy of Death Record
TC-02 Rev.6/20
TC-02 Page 1of 2
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independ
ence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
DEATH CERTIFICATES
The Brookhaven Town Clerk’s Office maintains death records for individuals who passed away in the Town of
Brookhaven, including deaths that occurred in Port Jefferson through December 31, 1963, and in the Villages of Lake
Grove and Mastic Beach to the present. Any deaths that occurred in the Village of Port Jefferson from January 1, 1964,
through the present are on file with the Village Clerk of Port Jefferson (631) 473-4724.
The only individuals eligible to obtain a death certificate include:
The surviving spouse of the
decedent.
A parent of the decedent.
A child or sib
ling of the decedent. In addition to the photo ID requirement listed below, a child or sibling
of the
decedent
must also include a copy of his/her birth certificate that lists
the parent(s).
An indivi
dual with notarized authorization from a person who is ent
itled to the certificate. If the applicant has
notarized authorization to
obtain the record on behalf of an eligible individual, the original notarized stat
ement
must accompany the request.
Other individuals who have a:
o Documented lawful right or claim. An example of a lawful right or claim would be if an applicant
needed the death certificate to claim a benefit. Documentation would consist of a letter from the
agency addressed to the applicant stating the requirement of a certified death certificate to process
the claim. The certificate will be sent directly to the agency or company that requires the document.
Please provide the address and name of a contact person.
o New York State Court Order
If the applicant’
s last name on the ID differs from the decedent’s name or from the applicant’s birth name
, please
provide a copy of the applicant’
s marriage certificate, legal name change paperwor
k, citizenship paper or
naturalization paper.
Identification Require
ments: Applications must be submitted with a copy of one of the following forms of valid
photo ID:
Driver’s license
DMV issued non-driver photo ID card
Passport
US Military ID
Permanent Resident Card
Employee ID with a recent pay stub
Two (2) utility or telephone bills dated within the last six (6) months.
ANY REQUESTS FOR A CERTIFICATE TO BE MAILED TO A POST OFFICE BOX OR TO A THIRD
PARTY MUST BE NOTARIZED.
Fee: $10.00 per certified copy requested. Payment may be made by check or money order payable to “Donna
Lent, Brookhaven Town Clerk”.
Application to Local Registrar
for Copy of Death Record
TC-02
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-02 (6/20) Page 2of 2
Applicants should mail the completed application to Town of Brookhaven Town Clerk's Office for a Copy of Death Record
form, with proper identification (see attached instructions for additional information or visit
www.brookhavenny.gov/departments/townclerk). Required ID and documents must be submitted with application. Fee:
$10 per copy or No Record Certification. Make check or money order payable to Donna Lent, Brookhaven Town Clerk. Please
do not send cash or stamps. Enclose photocopy of required documents and a self-addressed, stamped envelope and fee.
CERTIFICATE INFORMATION
1. Name of Deceased:
First Middle Last
2. Date of Death or Period to be Covered by Search: 3. Birth Date of Deceased: MM/DD/YYYY 4. Age at Death:
5. Birth Name of Father/Parent of Deceased:
First Middle Last
6. Death Certificate No.: (if known)
7. Birth Name of Mother/Parent of Deceased:
First Middle Last
8. Local Registration No.: (if known)
9. Place of Death:
Name of Hospital or Street Address Village, Town or City County
10. Purpose for Which Record is Required:
APPLICANT INFORMATION
11. What was your relationship to person whose record is
required?:
12. In what capacity are you acting?:
Submit documentation of a lawful right or claim if you are not the spouse, parent or child of the deceased.
13. If attorney, give name and relationship of your client to person whose record is required:
14. Signature of Applicant: 15. Date:
16. Name and Address of Applicant: 17. Address Where Record Should Be Sent: (If delivery is to a P.O.
Box or third party, you must submit with this application a notarized
statement signed by the applicant and a copy of the applicant’s driver’s
license.)
18. Telephone No. of Applicant
( )
19. No. of Copies Requested:
______ With Cause of Death
______ Without Cause of Death
20. Amount Enclosed:
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Completed 11 July 2020

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