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New York State Department of Health Vital Records Section Application to Local Registrar for Copy of Birth Record Name: (as listed on birth certificate) Date of Birth: First Middle Last (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) Local Registration No.: (If known) Father: (as listed on birth certificate) Number of Copies Requested: Purpose for which Record is Required: (Check one) Passport Social Security Retirement Other (specify) Employment Working Papers School entrance Driver license Marriage license Welfare assistance Veterans benefits Court proceeding Entrance into Armed Forces What is your relationship to person whose record is required? (If self, state "SELF".) If attorney, give name and relationship of your client to person whose record is required: Date Signed: Signature of Applicant: Month Day Year Address of Applicant: (Applicants Name) (Street) (City) (State) (Zip) Telephone No.: ( ) DOH-296A (06/2005) A. One of the following forms of valid photo-ID: B. Utility or telephone bills Two of the following showing the applicants name and address: Letter from a government agency dated within the last six 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 Employment ID FOR REGISTRARS USE ONLY (Photocopy ID and attach to application form) Type of ID: -OR- Other ID, Specify Number: Type: Number: Type: Issuing state: Expiration date: Number: Driver License First Middle Maiden Last First Middle Last Fee: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification If request is not from child/parents named on the requested certificate, notarized authorization is required.