Application to Local Registrar
for Copy of Death Record
Donna Lent, Town Clerk TC-02 Supplement A
Patricia Ryan, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-02 Supplement A (1/14) Page 1of 1
Notarized Authorization to Mail a Death Certificate to a Post Office Box
or Third-Party Address
I, ________________________, hereby authorize the Office of the Town Clerk of the Town of Brookhaven to
mail the requested death certificate to:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.
____________________________ __________________
Signed Phone Number
____________________________
Date
STATE OF ___________________
COUNTY OF _________________
On the _____ day of _______________ in the year ________, before me, the undersigned, personally appeared
______________________ proved to me on the basis of satisfactory evidence to be the individual whose name
is subscribed to the within instrument and acknowledge that he executed the same in his capacity, and that by
his signature on the instrument, the individual, or the person upon behalf of which the individual acted,
executed the instrument.
_______________________________
Notary Public
