Form Doh-296a - Application To Local Registrar For Copy Of Birth Record

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NEW YORK STATE DEPARTMENT OF HEALTH
Application to Local Registrar
Vital Records Section
For Copy of Birth Record
CERTIFICATE INFORMATION
First
Middle
Last
Date of Birth
__ __ __ __
__ __ __ __
Name
M M
D D
Y Y Y Y
Hospital (if not hospital, give street & number)
Village, Town or City
County
Pace of
Birth
First
Middle
Last
Mother’ s
First
Middle
Last
Father’ s
Maiden
Name
Name
Number of Copies Requested
Enter Birth No. if Known
Enter Local Registration No. if Known
__ Working Papers
__ Welfare Assistance
__ Passport
__ School Entrance
__ Veteran’ s Benefits
__ Social Security-Retirement
Purpose for which
__ Driver’ s License
__ Court Proceeding
__ Social Security SSI
Record is Required
__ Marriage License
__ Entrance into Armed Forces
__ Retirement
(Check One)
__ Employment
__ Other (specify) __________________________________________________________
APPLICANT INFORMATION
First
Middle
Last
If attorney, give name and relationship of your client to
Name
person whose record is required
What is your relationship to person whose record is
______________________________ ________________
required?
Name of Client
Relationship
__ Self __ Parent __ Other, specify ___________________
Telephone No. ( __ __ __ ) __ __ __ - __ __ __ __
FOR REGISTRAR’ S USE ONLY
Social Security No. __ __ __ - __ __ - __ __ __ __
TYPE OF ID
Signature of Applicant
Date
(Photocopy ID and attach to application form)
__ __ __ __ __ __
___ Driver’ s License
M M
D D
Y Y
State ____ No. ___________________
Address of Applicant
___ Other ID, specify
_______________________________________________
_______________________________
Street
_______________________________________________
No. ____________________________
City
State
Zip Code
TYPES OF ACCEPTABLE IDENTIFICATION
1. Driver’ s license
5. Military ID
2. Non-driver’ s license
6. Employer’ s Photo ID
3. Passport
7. Two utility bills, showing applicant’ s name and address
4. Naturalization Papers
8. Police report of lost or stolen ID
DO NOT ISSUE COPY UNLESS ONE OF THE ABOVE TYPES OF IDENTIFICATION IS PRESENTED
DOH-296A (11/94)

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