Application To Local Registrar For Genealogical Services Form - New York State Department Of Health
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1Application to Local Registrar
NEW YORK STATE DEPARTMENT OF HEALTH
for Genealogical Services
Vital Records Section
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
FEE - $22.00 includes search and uncertified copy or notification of no record.
1. Original records of births and marriages for the entire state begin with 1881, deaths begin with 1880, EXCEPT for records filed
in Albany, Buffalo and Yonkers prior to 1914. Applications for these cities should be made directly to the local office.
2. The New York State Department of Health does not have New York City records except for births occurring in Queens and
Richmond counties for the years 1881 through 1897.
To insure a complete search, provide as much information as possible. Please complete for
type of record requested, birth, death OR marriage.
Name at Birth __________________________________
Name at Birth __________________________________
Date of Birth ___________________________________
Date of Birth ___________________________________
Place of Birth ___________________________________
Place of Birth __________________________________
Father’s Name __________________________________
Father’s Name _________________________________
Mother’s Maiden Name __________________________
Mother’s Maiden Name _________________________
Name of Bride __________________________________
Name of Bride _________________________________
Name of Groom _________________________________
Name of Groom ________________________________
Date of Marriage ________________________________
Date of Marriage _______________________________
Place of Marriage
Place of Marriage
And/or License _________________________________
And/or License _________________________________
Name at Death _________________________________
Name at Death _________________________________
Date of Death _______________ Age at Death ________
Date of Death _______________ Age at Death _______
Place of Death __________________________________
Place of Death _________________________________
Name of Parents ________________________________
Name of Parents _______________________________
Name of Spouse ________________________________
Name of Spouse ________________________________
For what purpose is information required? ____________________________________________________________
What is your relationship to person whose record is requested? ____________________________________________
In what capacity are you acting? _____________________________________________________________________
SIGNATURE OF APPLICANT _________________________________________ DATE ___________________________
ADDRESS _______________________________________________________ Phone ___________________________
Send record to: (please print)
If requesting birth and marriage records, please sign the following
statement:
Name _____________________________________________________
To the best of my knowledge, the person(s) named in the application
are deceased.
Address ___________________________________________________
SIGNATURE OF APPLICANT
City ______________________ State _______ Zip Code ____________
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