Fillable Doh 4380 (New York)

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Doh 4380 (New York)

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File type: PDF

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DOH-4380 (09/19) p 1 of 2
Instructions
• Complete a separate application for each record requested.
• Use this application to mail your request.
• Use this application if you are the person named on the birth certificate or if you are that person’s parent.
• Use this application if the birth occurred in New York State
outside
of New York City.
Do not use this application if the birth occurred in any of the 5 boroughs of
New York City or Long Island Jewish Medical Center
.
For NYC birth call 212-639-6375 or visit http://www.nyc.gov/vitalrecords/
• Do not use this application for genealogy requests.
For genealogy requests: https://www.health.ny.gov/vital_records/genealogy.htm.
Enclose These Documents and Payment With Your Application
Required Identification. You must send your application with copies of documents from List A or List B.
Note: You need to include a copy of your passport if the request is made from a foreign country that requires a U.S. Passport for travel.
List A
Send a copy of 1 of the documents listed below. The document must include your photo and signature. It must also be current (not expired):
• Driver license
• Non-driver ID Card
• Passport
• Other government issued photo-ID
List B
If you do not have one of the documents in List A, send copies of 2 documents from List B. Each document should show your name and address.
• Utility bill
• Telephone bill
• Letter from a government agency dated within the last 6 months
Fees: If no birth record is on file, you will receive a document stating this. The document is called a No Record Certification.
Your application fee will not be refunded.
• The total fee for one copy is $30. Total for 2 copies is $60., etc.
• Send check or money order payable to the New York State Department of Health. Do not send cash.
Note: Payment submitted from foreign countries must be made by a check drawn on a U.S. bank or by international money order. Do not send cash.
How to Mail the Application
• Mail application along with check or money order and a copy of the required documentation (see below).
Send by first class mail, registered mail, certified mail or U.S. Priority Mail to:
New York State Department of Health
Bureau of Vital Records Certification Unit
PO Box 2602
Albany, NY 12220-2602
• Be sure to sign the form before mailing and include a check or money order made payable to the New York State Department of Health along
with copies of the required identification.
Mail-in Application for Copy of Birth Certificate
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
DOH-4380 (09/19) p 2 of 2
Do not use this application if the birth occurred within the five boroughs of New York City.
Mail-in Application for Copy of Birth Certificate
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Required ID documents must be sent with this application. Also enclose a check or money order payable to the New York State Department of
Health. Include notarized statement (if required). Be sure to sign the form.
Certifed copy processing:
Enclose $30 per copy.
If no record is found, your fee will not be refunded.
Send to: New York State Department of Health
Bureau of Vital Records Certification Unit
PO Box 2602
Albany, NY 12220-2602
Name: (as listed on birth certificate)
First Middle Last
Date of Birth:
mm / dd /yyyy
Town, City or Village Where Birth Occurred: Birth Certificate Number: (If known)
Name of Hospital Where Birth Occurred: (If known) Local Registration Number: (If known)
Birth/Pre-marriage Name of Mother/Parent: (As listed on Birth Certificate)
First Middle Last
Father/Parent: (As listed on Birth Certificate)
First Middle Last
Reason for Requesting the Record: (Check one)
Passport Employment Driver’s License Veteran’s Benefits Other (specify)
Social Security Working Papers Marriage License Court Proceeding
Retirement School Entrance Welfare Assistance Entrance into Armed Forces
Copy of Certificate of Birth Data for Foreign-born, Adopted Child.
Specify Country: Certificate “A” Number (If known)
What is your relationship to person whose record is required? (If self, state “Self”.)
If you are an attorney, give name and relationship of your client to person whose record is required:
The person/parent requesting information MUST complete and sign the box below.
Applicant
$30.00 x
Certifed Copy:
Copies = $
Name
Print
Signature Date Signed
mm / dd /yyyy
Name and address where record should be sent.
(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 driver’s license.)
Name
Print
Address
Street
City State Zip
Address
Street
Telephone Number:
( )
City State Zip
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Doh 4380 (New York)

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Completed 15 July 2020

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