For Copy of Death Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Empire State Plaza
Albany, New York 12237-0023
PLEASE COMPLETE FORM AND ENCLOSE FEE
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
PLEASE PRINT OR TYPE
Name of Deceased
First Middle Last
Date of Death or period to be Covered by Search
Name of Father of Deceased
First Middle Last
Social Security Number of Deceased
Name of Mother of Deceased
First Middle Last
Date of Birth of Deceased
Month Day Year
Age at Death
Place of Death
Name of Hospital or Street Address Village, Town or City County
Purpose for Which Record is Required
What was your relationship to the deceased? ______________________________________________________________
In what capacity are you acting? ________________________________________________________________________
If attorney, name and relationship of your client to deceased __________________________________________________
Signature of Applicant _____________________________________________________ Date ______________________
Address of Applicant _________________________________________________________________________________
PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT
Name ____________________________________________________________________________________________
Address __________________________________________________________________________________________
City __________________________________ State ______________________ Zip Code ________________________
DOH-294A (7/92) VS-34D
