Form Doh-4065 - Adoption Information Registry Birth Parent Registration Form - New York State Department Of Health
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1
2Adoption Information Registry
Birth Parent Registration Form
New York State
Department of Health
COMPLETE THIS APPLICATION
REGISTRY NUMBER
AND RETURN TO:
DATE
New York State Department of Health
Adoption Information Registry
OFFICIAL USE ONLY
P.O. Box 2602
Albany, NY 12220-2602
(518) 474-9600
Please indicate if this registration is to: (check all that apply)
Register for identifying information (Adoptee must be 18 years of age or older)
Submit medical information diagnosed after the adoption (No age restriction)
Medical information must be submitted on medical care provider's letterhead and include: medical care provider's
name, address, telephone number, and signature.
1. Name and address of birth mother
LAST
FIRST
MIDDLE
MAIDEN
CURRENT MAILING ADDRESS
STREET
CITY/TOWN
(
)
STATE
ZIP CODE
CURRENT TELEPHONE NUMBER
MONTH
DAY
YEAR
BIRTH MOTHER'S DATE OF BIRTH
2. Were you married at the time of the child's birth?
YES
NO
IF YES, NAME OF HUSBAND
3. List any other name you may have been using at the time of the child's birth, (i.e., former
married name, assumed name, alias, etc.)
4. Name and address of birth father
MONTH
DAY
YEAR
LAST
FIRST
MIDDLE
BIRTH FATHER'S DATE OF BIRTH
CURRENT MAILING ADDRESS
STREET
CITY/TOWN
(
)
CURRENT TELEPHONE NUMBER
STATE
ZIP CODE
Page 1 of 2
DOH-4065 (9/2000)
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