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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: Death Certificate No.: (If known) First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (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: What is your relationship to person whose record is required? In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: 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 Application to Local Registrar for Copy of Death Record 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 -OR- Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with confidential cause of death Copies requested without confidential cause of death Date Signed: Signature of Applicant: Month Day Year Address of Applicant: (Applicants Name) (Street) (City) (State) (Zip) Telephone No.: ( ) FOR REGISTRARS 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: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification