Form Lb-296a-M - Application To Local Registrar For Copy Of Birth Record By Mail - City Of Long Beach

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CITY OF LONG BEACH – NEW YORK
Application to Local Registrar
Office of the City Clerk
for Copy of Birth Record by Mail
CERTIFICATE INFORMATION
First
Middle
Last
Date of Birth
_____ ______ _________
Name
M M
D D
Y Y Y Y
Hospital
(Village, Town or City)
County
(if not hospital, give street & number)
Place of
Birth
LONG BEACH
NASSAU
First
Middle
Last
First
Middle
Last
Maiden Name
Father
of Mother
Number of Copies Requested
Enter Birth No.
Enter Local Registration
If Known
No. if Known
Passport
Working Papers
Welfare Assistance
Purpose for Which
Social Security – Retirement
School Entrance
Veteran’s Benefits
Record is Required
(Check One)
Social Security – SSI
Driver’s License
Court Proceeding
Retirement
Marriage License
Entrance Into Armed
Employment
Forces
Other (Specify)
APPLICANT INFORMATION
First
Middle
Last
Address of Applicant
Name
__________________________________________________
Street
What is your relationship to person whose record is
required?
__________________________________________________
City
State
Zip Code
Self
Parent
Other, specify ___________________
Telephone No. (
) ________-_______________
If Attorney, give name and relationship of your client to person
whose record is required
Social Security No. __________-______-__________
(name of client)
(relationship)
Signature of Applicant – Signature must be notarized
FOR REGISTRAR’S USE ONLY
Signature
Date
TYPE OF ID
Driver’s License
SWORN TO BEFORE ME THIS___________ DAY
State
No.
OF________________________________, 20_______
_____________________________________________
Other ID, specify
NOTARY PUBLIC
No.
LB-296A-M (11/09) Page 1 of 2

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