Fillable General Information and Application for Genealogical Services (Town of Hempstead)

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General Information and Application for Genealogical Services (Town of Hempstead)

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Information Page  Mail-in Application for Genealogical Services
General Instructions
 Use this application only for genealogy requests.
 Print a copy of this application, complete and sign.
Mail application with check or money order and a copy of any required documentation (see below) to:
New York State Department of Health
Vital Records Section
Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
Fees: If no record is on file, a No Record Report will be issued and the fee is not refunded.
For standard search: This includes a three (3) year search. The fee is $22.00 per copy. The fee is for each
name or type of record requested.
For long search: When more than a three-year search is requested, the fee for each record in need of a longer
search is higher according to the following schedule:
The fee applies separately to each record
requested. For example, the fee for a request
consisting of one birth record (1-year search), plus
one death record (24-year search), plus one
marriage record (11-year search) is a total of
$166.00 ($22 + $82 + $62 = $166)
1 - 3 years $22.00
4 - 10 years $42.00
11 - 20 years $62.00
21 - 30 years $82.00
31 - 40 years $102.00
41 - 50 years $122.00
51 - 60 years $142.00
61 - 70 years $162.00
 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 United States bank or by
international money order. Do not send cash.
Processing Time
Available Records
No information shall be released from a record unless the person to whom the record relates is known to the
applicant to be deceased.
No information shall be released unless the record has been on file for a minimum required period: birth records
must have been on file for at least 75 years, death records for 50 years, marriage records for 50 years (both parties
to the marriage must be deceased).
The time periods above are waived if the applicant is a descendant and provides documentation of direct line
descent. A party acting on behalf of a descendant shall further provide documentation that the descendant
authorized the party to make such application.
Completing the Form
If you are using Adobe Reader 5.0 or newer (available as a free download from www.adobe.com) you can fill in
the form directly in Adobe Reader by clicking on the appropriate space and entering the information (use the TAB
key to move to the next field, shift-TAB to move backwards). Print the completed form, sign and mail to the
address shown above.
®
You can print out a blank copy of the form and then type or print the required information.
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 any required documentation.
DOH-4384 (12/05) Page 1 of 2
For the latest information on processing times, please visit our web page at:
www.nyhealth.gov/vital_records/processingtime.htm
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
General Information and Application for Genealogical Services
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section, Genealogy Unit
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
1. FEE - $22.00 includes search and uncertified copy or notification of no record.
2. Original records of births and marriages for the entire state begin with 1881, deaths begin with 1880, EXCEPT for records filed in Albany,
Buffalo and Yonkers prior to 1914. Applications for these cities should be made directly to the local office.
3. The New York State Department of Health does not have New York City records except for births occurring in Queens and Richmond
counties for the years 1881 through 1897.
4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical research.
To insure a complete search, provide as much information as possible.
Please complete the applicable section for each type of record requested: birth, death or marriage.
Birth
Birth
Name at Birth Name at Birth
State File
Number
State File
Number
Date of Birth Date of Birth
Place of Birth Place of Birth
Fathers Name Fathers Name
Mothers Maiden Name Mothers Maiden Name
Marriage
Marriage
Name of Bride Name of Bride
Name of Groom Name of Groom
State File
Number
State File
Number
Date of Marriage Date of Marriage
Place of Marriage
and/or License
Place of Marriage
and/or License
Death
Death
Name at Death Name at Death
Age at Death Age at Death
Date of Death Date of Death
Place of Death Place of Death
Names of Parents Names of Parents
Name of Spouse Name of Spouse
State File Number State File Number
For what purpose is information required?
What is your relationship to person whose record is requested?
In what capacity are you acting?
SIGNATURE OF APPLICANT DATE
Address
Phone
If requesting birth and marriage records, please sign the following
statement:
To the best of my knowledge, the person(s) named in the application
are deceased.
Send record to: (please print)
Name
Address
City State Zip Code
SIGNATURE OF APPLICANT
DOH-4384 (12/05) Page 2 of 2
General Information and Application for Genealogical Services
Return to: New York State Department of Health, Vital Records Section, P.O. Box 2602, Albany, NY 12220-2602
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General Information and Application for Genealogical Services (Town of Hempstead)

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Completed 3 August 2020

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