Form Doh-296a - Application To Local Registrar For Copy Of Birth Record
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1Application to Local Registrar
New York State Department of Health
for Copy of Birth Record
Vital Records Section
Fee: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification
Application must be submitted with copies of either A or B.
Identification Requirements:
(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:
B.
Two (2) of the following showing the applicants name
-OR-
and address:
Driver license
Non-driver photo-ID card
Utility or telephone bills
Passport
Letter from a government agency dated within the
Employment ID
last six (6) months
Name:
Date of Birth:
(as listed on birth certificate)
(mm / dd / yyyy)
First
Middle
Last
Town, city or village where birth occurred:
Name of hospital where birth occurred:
(If known)
Maiden Name of Mother:
Local Registration No.:
(as listed on birth certificate)
(If known)
First
Middle
Maiden Last
Number of Copies
Father:
(as listed on birth certificate)
Requested:
First
Middle
Last
Purpose for which
Passport
Employment
Driver license
Veterans benefits
Social Security
Working Papers
Marriage license
Court proceeding
Record is Required:
(Check one)
Retirement
School entrance
Welfare assistance
Entrance into
Armed Forces
Other (specify)
If request is not from child/parents named on the requested certificate, notarized authorization is required.
What is your relationship to person whose
If attorney, give name and relationship of your client to person whose record is required:
record is required? (If self, state "SELF".)
Date Signed:
FOR REGISTRARS USE ONLY
Month
Day
Year
Signature of Applicant:
(Photocopy ID and attach to application form)
Type of ID:
Driver License
Issuing state:
Address of Applicant:
Expiration date:
(Applicants Name)
Number:
Other ID, Specify
(Street)
Number:
Type:
(City)
(State)
(Zip)
Number:
Telephone No.: (
)
Type:
DOH-296A (06/2005)
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