NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
PLEASE COMPLETE FORM AND ENCLOSE FEE
Initial copy or No Record Certification is free. Additional copies are $30.00 each. Make money order or
check payable to New York State Department of Health. Please do not send cash or stamps. Return
with required fee to: Certification Unit, Vital Records Section, P.O. Box 2602, Albany, NY 12220-2602.
FEE:
PLEASE PRINT OR TYPE
Maiden Name of Patient
First Middle Last
Address
Street Address Village, Town or City Zip Code
Patient's Date of Birth Social Security Number of Patient (last 4 digits only)
Month Day Year
Name of Facility
Street Address Village, Town or City Zip Code
Certifying Doctor's Name
Name of Funeral Director - Check box if none
Street Address Village, Town or City Zip Code
Date of Fetal Death Date of Disposition
Month Day Year Month Day Year
Name of Fetus - Check box if a name was not entered on the Fetal Death Certificate
First Middle Last
Name of Father - Check box if a name was not entered on the Fetal Death Certificate
First Middle Last
Sworn to Before me this
Day of , Signed
(Patient)
(Notary Public) NOTE: Signature must be notarized.
PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT
( )
Name Telephone
Address
City State Zip Code
DOH-3667 (06/2003)
