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Get NY VR 67 2014

Office of Vital Records 125 Worth Street CN-4 Room 133 New York N.Y. 10013-4090 SEE INSTRUCTIONS AND APPLICABLE FEES BELOW AND ON BACK DO NOT WRITE IN THIS SPACE OFFICE USE ONLY BIRTH CERTIFICATE APPLICATION Please Print Clearly 1. HOW MANY COPIES DO YOU NEED 13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE SELF/PARENT/OTHER please explain PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW NAME STREET ADDRESS APT. NO. CITY STATE ZIP CODE DAYTIME PHONE NUMBER Area Code Telephone Number E-MAIL ADDRESS NOTE Copy of a birth record can be issued only to persons to whom the record of birth relates if of age or to a parent or human service organizations. It is a violation of law to make a false untrue or misleading statement or forge the signature of another on this application. Violations are a misdemeanor punishable by a fine of up to 2 000. GOV/VITALRECORDS VR 67 Rev. 01/14 IMPORTANT BIRTH CERTIFICATE INFORMATION You can obtain a birth certificate for yourself if you are at least 18 years old or for your child with current identification. Detailed instructions for attorneys submitting requests on behalf of their clients are available online at www. LAST NAME ON BIRTH CERTIFICATE 2. FIRST NAME FEMALE 4a* IF YOU KNOW THE EXACT DATE OF BIRTH MM DD 4b. IF YOU DON T KNOW THE EXACT DATE OF BIRTH BEGIN END SEARCH YYYY MALE SEE BELOW FOR FEE INFORMATION 5. NAME OF HOSPITAL OR ADDRESS WHERE BORN 6. BOROUGH WHERE BORN 7. MOTHER/PARENT S NAME PRIOR TO FIRST MARRIAGE MAIDEN NAME FIRST LAST 9. FATHER/PARENT S NAME PRIOR TO FIRST MARRIAGE 10. WHY DO YOU NEED THIS BIRTH CERTIFICATE 11. DO YOU NEED A LETTER OF EXEMPLIFICATION YES NO 12. HOW MANY COPIES DO YOU NEED 13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE SELF/PARENT/OTHER please explain PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW NAME STREET ADDRESS APT. NO. CITY STATE ZIP CODE DAYTIME PHONE NUMBER Area Code Telephone Number E-MAIL ADDRESS NOTE Copy of a birth record can be issued only to persons to whom the record of birth relates if of age or to a parent or human service organizations. It is a violation of law to make a false untrue or misleading statement or forge the signature of another on this application* Violations are a misdemeanor punishable by a fine of up to 2 000. 15. CUSTOMER COMMENTS/ADDITIONAL INFORMATION 14. CUSTOMER SIGNATURE AND DATE SIGNATURE DATE APPLICATIONS SUBMITTED BY MAIL MUST BE NOTARIZED FEES 15 per copy x copies NOTARY PUBLIC SEAL Cost of certified copy includes a two consecutive year search COUNTY OF 3 for each extra year searched x years SUBSCRIBED AND SWORN BEFORE ME Total Amount Enclosed IF RECORD IS NOT ON FILE A CERTIFIED NOT FOUND STATEMENT WILL BE ISSUED. CASH IS NOT ACCEPTED BY MAIL OR IN PERSON* THIS DAY OF 20 ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT WWW*NYC. nyc*gov/vitalrecords. Falsifying information including forging a signature to obtain a birth certificate is a misdemeanor and violators may also be subject to a fine of up to 2 000 per violation* Credit cards are not accepted for mail-in orders.

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