Fillable pplication to Local Registrar for Copy o Birth (Tompkins County Information Technology Services)

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pplication to Local Registrar for Copy o Birth (Tompkins County Information Technology Services)

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BROWSE TOMPKINS COUNTY INFORMATION TECHNOLOGY SERVICES (NY) FORMS

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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
A
pplication
to Local Registrar for Copy o
f
Birth
Certificate
DOH-4380 (12/05) Page 1 of 2
TCHD (10/14) (12/16) (09/17)
General Instructions
• Do not use this application to submit your request by fax.
• Use this application only if you are the person named on the birth certificate or that person's parents.
• Use this application only if the birth occurred in New York State outside of New York City. Do not
use this application if the birth 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 along with check or money order and a copy of the required documentation (see below).
For regular handling send by first class mail, registered
mail, certified mail or U.S. Priority Mail to:
Tompkins County Health Department
Vital Records Section
55 Brown Road
Ithaca, NY 14850
Identification Requirements: Application must be submitted with acceptable identification:
Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.
A. One (1) of the following forms of valid photo-ID:
• Driver license
• Non-driver license
• Passport
• Naturalization Papers
• Military ID
• Employer’s Photo ID
• Police report of lost or stolen ID
B. T
wo (2) of the following showing the applicant's name and address:
• U
tility bill or telephone bill
• Letter from a government agency dated within the last six (6) months
Fee per transaction:*
•
$30 for the first certified copy, $15 for each additional copy
*One transaction refers to one customer ordering a single record at any one time.
Information Page - Mail-in Application for Copy of Birth Certificate
---- OR ----
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
A
pplication
to Local Registrar for Copy o
f
Birth
Certificate
DOH-4380 (12/05) Page 2 of 2
TCHD (10/14) (12/16) (09/17)
Required ID must be included with application. Make check or money order payable to Tompkins County Health Department.
Enclose $30 per copy and completed form to:
Tompkins County Health Department
Vital Records Section
55 Brown Road
Ithaca, NY 14850
Name: (as listed on birth certificate)
First Middle Last
Date of Birth:
(mm / dd / yyyy)
Town, city or village where birth occurred: Name of hospital where birth occurred: (If known)
Maiden Name of Mother: (as listed on birth certificate)
Birth Certificate No.:
(If known)
First Middle Maiden Last
Local Registration No.:
(If known)
Father: (as listed on birth certificate)
Number of Copies Requested:
First Middle Last
Purpose for which Passport Employment Drivers license Veteran's benefits
Record is Required: Social Security Working Papers Marriage license Court proceeding
(Check one)
Retirement
School entrance Welfare assistance Entrance into
Other (specify) Armed Forces
Wh
a
t
i
s your re
l
a
ti
ons
hi
p
t
o person w
h
ose
record is required? (If self, state "SELF".)
If attorney, give name and relationship of your client to person whose record is required:
This office requires written authorization of the person/parents whose record is requested.
Signature of Applicant:
Date Signed:
Month Day Year
FOR REGISTRAR’S USE ONLY
(Photocopy ID and attach to application form)
TYPE OF ID:
Driver’s License
Other ID, specify
# ISSUED
AMOUNT PAID:
CHECK OR CASH RECEIPT #
(CIRCLE ONE)
DATE ISSUED:
INITIALS OF PERSON ISSUING
CERTIFICATE/TRANSCRIPT #
Address of Applicant:
(Applicant's Name)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
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pplication to Local Registrar for Copy o Birth (Tompkins County Information Technology Services)

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Completed 12 June 2021

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