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Information Page Mail-in Application for Copy of Death Certificate General Instructions Do not use this application for fax requests. Use this application if you are the spouse, parent or child of the deceased. If you are not the spouse, parent or child of the deceased, then you must submit with this application a copy of documentation establishing a lawful right or claim (see below). Use this application only if the death occurred in New York State outside of New York City. Do not use this application if the death occurred in any of the five boroughs of New York City. Do not use this application for genealogy requests. Print a copy of this application, complete and sign. Mail application with check or money order and a copy of any required documentation (see below). For regular handling send by first class mail, registered mail, certified mail or U.S. Priority Mail to: For priority handling (add $15.00 per copy ordered), submission by overnight carrier is recommended. Send to: New York State Department of Health Vital Records Section Certification Unit P.O. Box 2602 Albany, NY 12220-2602 New York State Department of Health Vital Records Section / 2nd Floor Certification Unit 800 North Pearl Street Menands, NY 12204 What is a lawful right or claim? If the applicant is not the spouse, parent or child of the decedent, a lawful right or claim must be documented. An example of a lawful right or claim would be a death record needed by the applicant to claim a benefit. Documentation would consist of a copy of a court order or an official letter verifying that a copy of the requested death record is required from the applicant in order to process a claim. Identification Requirements Application must be submitted with copies of either A or B: One of the following forms of valid photo-ID: A. Driver license Non-Driver Photo-ID Card Passport Other government issued photo-ID Two of the following showing the applicants name and address: B. Utility or telephone bills Letter from a government agency dated within the last six months Fees: If no record is on file, a No Record Certification is issued and the fee is not refunded. For regular handling: The fee is $30.00 per copy. Total for one copy is $30.00. Total for two copies is $60.00, etc. For priority handling: The fee is $30.00 + $15.00 per copy Total for one copy is $45.00. Total for two copies is $90.00, etc. Submitting the application by overnight carrier is recommended. Completed requests will be returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request. Send check or money order payable to the New York State Department of Health. Do not send cash. Note: Payment submitted from foreign countries must be made by a check drawn on a United States bank or by international money order. Do not send cash. Processing Time For the latest information on processing times, please visit our web page at www.nyhealth.gov/vital_records/processingtime.htm For faster processing, you may wish to use your credit card and submit your request by e-mail, fax, or telephone. Completing the Form If you are using Adobe Reader 5.0 or newer (available as a free download from www.adobe.com) you can fill in the form directly in Adobe Reader by clicking on the appropriate space and entering the information (use the TAB key to move to the next field, shift-TAB to move backwards). Print the completed form, sign and mail to above address. You can print out a blank copy of the form and then type or print the required information. Be sure to sign the form before mailing and include a check or money order made payable to the New York State Department of Health along with copies of any required documentation. DOH-4376 (12/05) Page 1 of 2 Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Mail-in Application for Copy of Death Certificate ---PAGE BREAK--- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Mail-in Application for Copy of Death Certificate 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: From To mm / dd / yyyy 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: Submit documentation of a lawful right or claim if you are not the spouse, parent or child of the deceased. Date Signed: Month Day Year Signature of Applicant: Regular Handling (Check Only One) Priority Handling $30.00 x OR $45.00 x Copies = $ Please print or type the name and address where record should be sent: (If delivery is to a P.O. Box or third party, you must submit with this application a notarized statement signed by the applicant and a copy of the applicants drivers license.) Address of Applicant: (Applicants Name) (Name) (Street) (Street) (City) (State) (Zip) Telephone No.: ( ) (City) (State) (Zip) DOH-4376 (12/05) Page 2 of 2 Required ID must be included with application. Make check or money order payable to New York State Department of Health. For regular handling: Enclose $30 per copy or No Record Certification. Send to: For priority handling: Enclose $45 per copy or No Record Certification. Submission by overnight carrier is recommended. Send to: New York State Department of Health Vital Records Section / Certification Unit 800 North Pearl Street - 2nd Floor Menands, NY 12204 New York State Department of Health Vital Records Section / Certification Unit P.O. Box 2602 Albany, NY 12220-2602