Fillable Printable Mail-in Application for Copy of Birth Certificate - New York
Fillable Printable Mail-in Application for Copy of Birth Certificate - New York
Mail-in Application for Copy of Birth Certificate - New York
Information Page Mail-in Application for Copy of Birth Certificate
General Instructions
Do not use this application to submit your request by fax.
Use this application only if you are the person named on the birth certificate or that persons parents.
Use this application only if the birth occurred in New York State outside of New York City. Do not use this
application if the birth occurred in any of the five (5) boroughs of New York City.
Do not use this application for genealogy requests.
Print a copy of this application, complete and sign.
Mail application along with check or money order and a copy of the required documentation (see below).
For regular handling send by first class mail, registered
mail, certified mail or U.S. Priority Mail to:
Certification Unit
Vital Records Section
New York State Department of Health
P.O. Box 2602
Albany, NY 12220-2602
Certification Unit
Vital Records Section / 2nd Floor
New York State Department of Health
800 North Pearl Street
Menands, NY 12204
Identification Requirements: Application mustbe submitted with copies of either A orB:
A. One (1) of the following forms of valid photo-ID:
Driver license
Non-driver license
Passport
Other government issued photo-ID
B. Two (2) of the following showing the applicants name and address:
Utility bill or telephone bill
Letter from a government agency dated within the last six (6) months
Fees: If no record is on file, a No Record Certificationis issued and the fee is notrefunded.
For regular handling: The fee is $30.00 per copy. Total for one (1) copy is $30.00. Total for two (2) copies is
$60.00, etc.
For priority handling: The fee is $30.00 + $15.00 per copy. Total for one (1) copy is $45.00. Total for two (2)
copies is $90.00, etc. Submitting the application by overnight carrier is recommended. Completed requests will be
returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request.
Send check or money order payable to the New York State Department of Health. Do not send cash.
Note:
Payment submitted from foreign countries must be made by a check drawn on a United States bank or by
international money order. Do not send cash.
Processing Time
Completing the Form
Ifyouare using Adobe Reader5.0ornewer(available asafree download from www.adobe.com) you can fill in the
form directly in Adobe Reader by clicking on the appropriate space and entering the information (use the TAB key to
move to the next field, shift-TAB to move backwards). Print the completed form, sign and mail to the above address.
®
You can print out a blank copy of the form and then type or print the required information.
Be sure to sign the form before mailing and include a check or money order made payable to the New York State
Department of Health along with copies of the required identification.
DOH-4380 (12/05) Page 1 of 2
Note:Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.
For the latest information on processing times, please visit our web page at
www.nyhealth.gov/vital_records/processingtime.htm
For faster processing, you may wish to use your credit card and submit your request by e-mail, fax, or telephone.
For priority handling (add $15.00 per copy ordered),
submission by overnight carrier is recommended. Send to:
Mail-in Application for Copy of Birth Certificate
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Mail-in Application for Copy of Birth Certificate
Name: (as listed on birth certificate)Date of Birth:
First Middle Last
(mm / dd / yyyy)
Town, city or village where birth occurred:Name of hospital where birth occurred: (If known)
Maiden Name of Mother: (as listed on birth certificate)
Birth Certificate No.:
(If known)
Local Registration No.:
(If known)
First Middle Maiden Last
Father: (as listed on birth certificate)
Number of Copies Requested:
Standard Size: Wallet Size:
First Middle Last
Purpose for which
Record is Required:
(Check one)
Passport
Social Security
Retirement
Other (specify)
Employment
Working Papers
School entrance
Drivers license
Marriage license
Welfare assistance
Veterans benefits
Court proceeding
Entrance into
Armed Forces
What is your relationship to person whose
record is required? (If self, state "SELF".)
If attorney, give name and relationship of your client to person whose record is required:
This office requires written authorization of the person/parents whose record is requested.
Date Signed:
Month Day Year
Signature of Applicant:
Regular Handling
(Check Only One)
Priority Handling
$30.00 x
OR
$45.00 x Copies = $
J
Please print or type the name and address where record
should be sent: (If delivery is to a P.O. Box or third party, you must submit
Address of Applicant:
with this application a notarized statement signed by the applicant and a copy of
the applicants drivers license.)
(Applicants Name)
(Name)
(Street)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
(City) (State) (Zip)
DOH-4380 (12/05) Page 2 of 2
Required ID must be included with application. Make check or money order payable to New York State Department of Health.
For regular handling: Enclose $30 per copy or No Record Certification.
Send to:
For priority handling: Enclose $45 per copy or No Record Certification.
Submission by overnight carrier is recommended. Send to:
New York State Department of Health
Vital Records Section / Certification Unit
800 North Pearl Street - 2nd Floor
Menands, NY 12204
New York State Department of Health
Vital Records Section / Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
