Fillable Direct Line Descendant Application for Copy of Pre-Adoption (New York State)

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Direct Line Descendant Application for Copy of Pre-Adoption (New York State)

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DO NOT USE this application if the birth occurred within the five boroughs of New York City.
DO NOT USE if you are the adoptee and you are seeking your own pre-adoption birth certificate. Instead, use the Adoptee Application for Copy
of Pre-Adoption Birth Certificate (DOH-5299).
USE this application if you are a direct line descendant (child, grandchild, great-grandchild, etc.) of an adoptee born in New York State (outside
of New York City), the adoptee is deceased and you are applying for a copy of the adoptee's pre-adoption birth certificate.
Required identification for the applicant must be sent with this application along with a copy of the adoptee's death certificate and
documentation of relationship to the adoptee. See instruction page for details.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Direct Line Descendant Application for Copy of Pre-Adoption Birth Certificate
Mail completed application and documents:
Enclose $45 per copy via check or money order payable
to the New York State Department of Health
Send to: New York State Department of Health
Bureau of Vital Records, PAC Unit
PO Box 2602
Albany, NY 12220-2602
Adoptee Name: as listed on most recent (post-adoption) birth certificate
First Middle Last
Date of Birth:
mm/dd/yyyy
Town, city or village of birth:
Birth Certificate Number: (if known)
Pre-Marriage Name of Adoptive Mother/Parent: (as listed on adoptee's most recent (post-adoption) birth certificate)
First Middle Last
Pre-Marriage Name of Adoptive Father/Parent: (as listed on adoptee's most recent (post-adoption) birth certificate)
First Middle Last
Applicant MUST complete and sign the box below.
Applicant Attestation: By signing, I attest that I am a direct line
descendant of the adoptee whose birth certificate is being requested
with this application.
Name
Print
DOH-5300 (1/20) p1 of 2
Applicant's relationship to adoptee:
(child, grandchild, great-grandchild, etc.)
FOR OFFICE USE ONLY
Certified Copy: $45.00 x Copies = $
Signature Date Signed
mm/dd/yyyy
Street Address
Street / Apt (No PO Box)
City State Zip
Telephone Number:
( )
Name and address where record should be sent:
NOTE: If delivery is to a P.O. Box, or to a third party,
you must enclose a notarized statement signed by the
applicant AND a copy of the applicant's government
issued identification.
Name
Print
City State Zip
Mailing Address
Instructions
This application should be used only by a direct line descendant of an adoptee to request a copy of the adoptee's original (pre-adoption)
birth certificate.
DO NOT USE if you are the adoptee and you are seeking your own pre-adoption birth certificate. Instead, use the Adoptee Application for
Copy of Pre-Adoption Birth Certificate (DOH-5299).
DO NOT USE this application if the birth occurred within the five boroughs of New York City. Contact the New York City Department of Health
and Mental Hygiene for ordering information.
NYC Web site: http://www.nyc.gov/vitalrecords
USE this application if you are a direct line descendant (child, grandchild, great-grandchild, etc.) of an adoptee born in New York State
(outside of New York City), the adoptee is deceased and you are applying for a copy of the adoptee's pre-adoption birth certificate.
• Complete the application with the adoptee's name as listed on their most recent (post-adoption) birth certificate.
• You should not put adoptee's birth name or birth parents' names on the application, even if you know them. To find the record, we
require the adopted information.
• When entering parents' names, enter the adoptive parents' names as they appear on the most recent (post-adoption) birth certificate.
• In the address and signature box, provide your current legal name and current mailing address.
Include Identification With Your Application
List A
Send a photocopy of one of the documents listed. The
document must include your photo and signature. It cannot
be expired.
• Driver license
• State issued Non-driver ID Card
• Passport
• Other government issued photo ID with signature and
expiration date
Fees: If no adoption is on file, you will receive a notification of no record instead of a birth certificate. The fee is not refunded.
• The fee is $45.00 per copy.
• Send a check or money order payable to the New York State Department of Health. Do not send cash.
• Payment from outside of the United States must be made by check drawn on a U.S. bank or by international money order.
How to Mail the Application
Enclose $45 per copy via check or money order payable to the New York State Department of Health
Send to: New York State Department of Health
Bureau of Vital Records, PAC Unit
PO Box 2602
Albany, NY 12220-2602
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Direct Line Descendant Application for Copy of Pre-Adoption Birth Certificate
DOH-5300 (1/20) p2 of 2
List B
If you do not have one of the documents in List A, you must send
two original documents from List B. Each must show your current
name and address. They must be from two different companies
and/or agencies. They must be dated within the last six months.
• Utility bill
• Telephone bill
• Letter from a government agency dated within the last 6
months
Identification is required. Send a photocopy of one from list A or original of two documents from list B.
Documentation of Direct Line Descent From Adoptee to Applicant
• Applicant must provide photocopy of adoptee's death certificate.
• Applicant must provide documentation of direct line descent from the adoptee. Direct line descent is parent to child to grandchild, etc.
• If the adoptee is your parent, include a photocopy of your birth certificate showing adoptee as your parent.
• If the adoptee is a grandparent, great-grandparent, etc., you will need to provide a photocopy of record(s) showing the line of descent
from adoptee to applicant (such as birth, death records).
• If there are any name changes in the line of descent you will also need to provide photocopies of marriage records, name change orders
or other records to show direct line descent.
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Direct Line Descendant Application for Copy of Pre-Adoption (New York State)

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Completed 14 August 2020

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