Fillable New York State Department of Health Vital Records (TOWN OF NORTH HEMPSTEAD)

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New York State Department of Health Vital Records (TOWN OF NORTH HEMPSTEAD)

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Name of Deceased: Social Security No. of Deceased:
First Middle Last
Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death:
mm / dd / yyyy
From To
Maiden Name of Mother of Deceased:
(If known)
First Middle Maiden Last
Name of Father of Deceased:
(If known)
First Middle Last
Place of Death:
Name of Hospital or Street Address Village, town or city County
Purpose for which Record is Required:
In what capacity are you acting?
DOH-294A (06/2005)
If you are not the parent or child of the deceased or the spouse of the deceased
at the time of death, you must submit documentation of a lawful right or claim.
New York State Department of Health
Vital Records Section
A. One (1) of the following forms of valid photo-ID:
B.
 Utility or telephone bills
Two (2) of the following showing the applicants name
and address:
Letter from a government agency dated within the
last six (6) months
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.)
 Driver license
 Non-driver photo-ID card
 Passport
 U.S. Military photo-ID
-OR-
Number of Copies Requested:
Copies requested
confidential cause of death
Copies requested
confidential cause of death
Date Signed:
Signature of Applicant:
Address of Applicant:
(Applicants Name)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
FOR REGISTRARS USE ONLY
(Photocopy ID and attach to application form)
Type of ID:
Other ID, Specify
Number:
Type:
Number:
Type:
Issuing state:
Expiration date:
Number:
Driver License
Total number of
copies requested
Fee: County District - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
Obtaining a Copy of a Death Record
There are three (3) types of death documents permitted for issue by NYS Public Health
Law.
They are:
Certified Copy
A photographic reproduction of the actual death certificate
Certified
Transcript
A computer- generated or other reproduction of information
abstracted from the actual death certificate
Certification
A computer- generated or other reproduction of only the name
of the person to whom the death relates, the date, place of
death, and the filing date.
A Certified Copy or Certified Transcript of death can be issued to the spouse, parent
or child of the deceased; to a lawful representative of the spouse, parent or child of the
deceased; to a person requiring the record for legal right or claim; documented medical
need, by NYS Court order or to a government agency when needed for an official
purpose.
A Certification of death can be issued to the spouse, parent or child of the deceased;
to a lawful representative of the spouse, parent or child of the deceased if and when
there is only need for documentation of death.
Forward Mail Requests To:
Registrar - Town of North Hempstead
200 Plandome Road P. O. Box 3000
Manhasset, New York 11030
Include a Stamped, Self-addressed envelope with:
1. A $10 Money Order for each copy ordered.
2. A Photo copy of the requestor’s Identification. (State Motor Vehicle
Driver’s license, Non-Driver I D, Passport or other birth related I D)
3. Give name, date or death, relationship to the decedent and reason
the death record is being requested.
Priority Handling
* In addition to the requirements above: Send request via FEDEX, USPS,
UPS or other overnight carrier and include a pre-paid, self-addressed
return envelop and applicable pick-up charges. (Example, UPS charges $
6.95 for pick-up of all pre-paid envelops & packages)
DOH-294A (06/2005) - instructions
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New York State Department of Health Vital Records (TOWN OF NORTH HEMPSTEAD)

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Completed 14 July 2020

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