Fillable Mail-in Application for Copy of Death Certificate (New York State)

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Mail-in Application for Copy of Death Certificate (New York State)

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DOH-4376 (11/13) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Mail-in Application for Copy of Death Certificate
Information Page — Mail-in Application for Copy of Death Certificate
General Instructions
• Use this application if you are the spouse, parent, child or sibling of the deceased.
• If you are not the spouse, parent, child or sibling of the deceased, then you must submit with this application a copy
of documentation establishing a lawful right or claim (see below).
• Use this application only if the death occurred in New York State outside of New York City. Do not use this
application if the death occurred in any of the five (5) boroughs of New York City.
• Do not use this application 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 o
rder by mail, send by first class mail, registered mail,
certified mail or U.S. Priority Mail to:
New York State Department of Health
Vital Records Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
What is a lawful right or claim?
• If the applicant is not the spouse, parent, child or sibling of the decedent, a lawful right or claim must be documented.
An example of a lawful right or claim would be a death record needed by the applicant to claim a benefit.
• Documentation would consist of a copy of a court order or an official letter verifying that a copy of the requested death
record is required from the applicant in order to process a claim.
Identification Requirements -- Application must be submitted with copies of either A or B:
Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.
EITHER
A.
One (1) of the following forms of valid photo-ID:
• Driver license
• Non-Driver Photo-ID Card
• Passport
• Other government issued photo-ID
OR
B.
Two (2) of the following showing the applicant's name and address:
• Utility or telephone bills
• Letter from a government agency dated within the last six months
Fees: If no record is on file, a No Record Certification is issued and the fee is
not refunded.
• The fee is $30.00 per copy. — Total for one (1) copy is $30.00. Total for two (2) copies is $60.00, 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 United States bank or by
international money order. Do not send cash.
Completing the Form
• If you are using Adobe Reader
®
(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. Print the completed form, sign and mail to above
address.
• 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.
For Expedited order placement and processing:
Please visit www.VitalChek.com
or call VitalChek Network, Inc. at 877-854-4481
DOH-4376 (11/13) Page 2 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Mail-in Application for Copy of Death Certificate
( )
√
Required ID must be included with application. Make check or money order payable to New York State Department of Health.
Mail Order Certified Copy: Enclose $30 per copy or No Record
Certification. Send to:
New York State Department of Health
Vital Records Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
Name of Deceased:
First Middle Last
Social Security No. of Deceased:
Date of Death or Period to be Covered by Search: (mm/dd/yyyy)
From To
Date of Birth of Deceased:
mm / dd / yyyy
Age at Death:
Mother/Parent of Deceased: (birth name)
First Middle Last
Death Certificate No.: (If known)
Father/Parent of Deceased: (birth name)
First Middle Last
Local Registration No.: (If known)
Place of Death:
Name of Hospital or Street Address Village, town or city County
Purpose for which Record is Required:
What is your relationship to person whose record is required?
In what capacity are you acting?
If attorney, give name and relationship of your client to person whose record is required:
Submit documentation of a lawful right or claim if you are not the spouse, parent, child or sibling of the deceased.
Signature of Applicant:
Date Signed:
Month Day Year
Address of Applicant:
(Applicant's Name)
(Street)
(City) (State) (Zip)
Telephone No.:
Certified Copy
$30.00 x
Copies = $
Please print or type the name and address where record
should be sent: (If delivery is to a P.O. Box or third party, you must submit
with this application a notarized statement signed by the applicant and a copy of
the applicant's driver license.)
(Name)
(Street)
(City) (State) (Zip)
For Expedited order placement and processing:
Please visit www.VitalChek.com
or call VitalChek Network, Inc. at 877-854-4481
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Mail-in Application for Copy of Death Certificate (New York State)

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Completed 14 August 2020

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