Fillable OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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1. LAST NAME AT TIME OF DEATH 2. FIRST NAME
13. MOTHER'S MAIDEN NAME (Name Before Marriage)
15. FOR WHAT PURPOSE ARE YOU GOING TO USE THIS CERTIFICATE
6. BOROUGH 7. AGE
5. PLACE OF DEATH
8. NO. OF COPIES 9. SPOUSE'S NAME
11. FATHER'S NAME
3. ❏ FEMALE
❏ MALE
10. OCCUPATION OF DECEASED
12. SOCIAL SECURITY NUMBER
14. BURIAL PERMIT NUMBER (IF KNOWN)
16. YOUR RELATIONSHIP TO DECEDENT
SIGN/PRINT YOUR NAME AND RECORD YOUR ADDRESS BELOW
FEES
SEARCH FOR TWO CONSECUTIVE YEARS AND ONE COPY $15.00
EACH ADDITIONAL COPY REQUESTED $15.00
EACH EXTRA YEAR SEARCHED (WITH THIS APPLICATION) $ 3.00
IF RECORD IS NOT ON FILE, A CERTIFIED "NOT FOUND STATEMENT" WILL BE ISSUED.
1. Make check or money order payable to: N.Y.C. Department of Health and Mental
Hygiene. CASH NOT ACCEPTED BY MAIL.
2. If from a foreign country, send an international money order or check
drawn on a U.S. Bank.
3. Stamps or foreign currency will not be accepted.
VR 66 (REV. 8/02)
NOTE: Section 205.07 of the Health Code provides, in part:" . . . The confidential medical report of death shall not be
subject to subpoena or to inspection." Therefore, copies of the medical report of death cannot be issued.
(FOR OFFICE USE ONLY)
APPLICATION FOR A COPY OF A DEATH RECORD
(Print All Items Clearly)
THE CITY OF NEW YORK – DEPARTMENT OF HEALTH AND MENTAL HYGIENE
OFFICE OF VITAL RECORDS
125 Worth Street, CN 4, Room 133
New York, N.Y. 10013-4090
SEE IDENTIFICATION REQUIREMENTS ON REVERSE
VEA REQUISITOS DE IDENTIFICACIÓN AL DORSO
4. DATE OF DEATH
Month Day Year
SIGNATURE PRINT NAME
ADDRESS
CITY
DAYTIME TELEPHONE NUMBER
STATE
APT. NO.
ZIP CODE
Area Code Telephone Number
NOTE: PLEASE ATTACH A STAMPED, SELF-ADDRESSED ENVELOPE
INFORMATION: APPLICATION SHOULD BE MADE IN PERSON AT 125 WORTH STREET OR BY MAIL TO THE ABOVE ADDRESS
I. Relatives of the Deceased: Generally, relatives
of the deceased are entitled to receive certified
copies of the death record.
ID Requirements: Valid, signed photo-
identification including; Driver’s License, Employee
ID, Government ID, Social Services ID, OR a
Passport.
Without valid Photo-ID: T
wo of the following
showing your name and address: Utility Bill(s),
Telephone Bill or Letter(s) from a Government
Agency.
II. Those Not Related to the Deceased: Only non-
relatives who are able to establish a right to the
certificate by providing documentation, are entitled
to receive a certified copy.
Documentation showing entitlement includes but is
not limited to; an Insurance Policy, a Bank Book, a
Property Deed, and a Will.
ID Requirements: Valid, signed photo-identification
including; Driver’s License, Employee ID,
Government ID, Social Services ID, OR a Passport.
Without valid Photo-ID: T
wo of the following
showing your name and address: Utility Bill(s),
Telephone Bill or Letter(s) from a Government
Agency, AND;
Documentation showing entitlement (see paragraph
#2 above).
Death Certificate Identification Requirements
There is no credit card service for Death Certificates.
Death Certificate walk-in orders are mailed.
I. Familiares del difunto: Generalmente, los
familiares del difunto tienen derecho a recibir copias
certificades del récord de defunción.
Requisitos de Identificación: Identificación válida
con fotografía y firmada; por ejemplo, licencia de
conducir, identificación de empleo, identificación de
gobierno, identificación de servicios sociales, o un
pasaporte.
Si no tiene una identificación válida con fotografía:
Dos
de los siguientes documentos que muestren su
nombre y dirección: Factura(s) de los servicios
públicos: teléfono, gas, electricidad, o carta(s) de una
agencia del gobierno.
II. Personas que no están emparentadas con el
difunto: Sólo aquellos que no son parientes y que
pueden establecer su derecho a que se les entregue el
certificado, mostrando documentos pertinentes,
tienen derecho a recibir una copia certificada.
La documentación que muestra derecho incluye,
pero no se limita a lo siguiente: una póliza de seguro,
una libreta de banco, la escritura (título) de una
propiedad y un testamento.
Requisitos de identificación: Identificación válida
con fotografía y firmada: incluyendo, licencia de
conducir, identificación de empleo, identificación de
gobierno, identificación de servicios sociales, o un
pasaporte.
Si no tiene identificación válida con fotografía: Dos
de los documentos siguientes mostrando su nombre y
dirección: Facturas del los servicios públicos, carta(s)
de una agencia del gobierno, y
Documentos que muestren su derecho (vea el párrafo
número 2 más arriba.)
Requisitos de Identificación para la Emisión de un Certificado de Defunción
No hay servicio de tarjetas de crédito para certificados de defunción. Los pedidos en
persona de certificados de defunción se enviarán por correo.
VR 66 (REV. 8/02)
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OFFICE OF VITAL RECORDS 125 Worth Street, CN (It's Easy)

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Completed 25 July 2021

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