Form Doh 299 – Fill Out and Use This PDF

	See Reverse Side for Instructions
Deceased	District	Number
Date of Death	Register	Number
Place of Death	State Number

I,

of

(name of applicant)

(address of applicant)

request that the following information amend the certificate of death identified above:

	ITEM IN ERROR	AS IT APPEARS	AS IT SHOULD BE
	(or omitted)

Documentary evidence submitted herewith in support of this application includes:

Explain reason for error or omission:

Under the penalties of pe~ury, I hereby affirmthat the statements made herein are true and correct to the best of my knowledge.

Signature of Applicant

Relationship to Deceased

Date

,The above information has been added to the local record of death on file in this office.

Signature of Registrar	District Number	Date
DOH-299 (6/99) Page 1 of2		(OVER)

	Instructionsfor Completing Correction Form
Purpose	This form may be used to correci Informationentered in error or to add information omitted at the
	time the original death certificate was filed. Any other change or alteration of information on a
	death certificate cannot be made without a court order

Signature This form should be completed and signed by:

1.The physician who signed the original death certificate. or

2.The individual who furnished the information for the original certificate.

Documentary 1. Documentary evidence IS NOT REQUIRED for the following changes:

Evidencea. ADDITION OF INFORMATION which was not available at the time the death certificate was originally filed.

b.MINOR CHANGES IN SPELLING OF GIVEN NAME OR SURNAME of deceased or parents (such as Smith to Smyth, Myer to Meyer, Bob to Robert, Jack to John, etc.). Any significant change in name or spelling of name must be documented, per instructions below.

c.A CHANGE OF ONE YEAR OR LESS IN DATE OF BIRTH OF DECEASED.

Documentation is required for a change of more than one year.

2.Documentary evidence IS REQUIRED for all other corrections and must be submitted with this form.

a.DOCUMENTS NORMALLY ACCEPTED AS PROOF FOR A CORRECTION ARE: birth certificate of deceased, marriage record, church or synagogue record, physician's office record, census record. A detailed listing of documents is enclosed, or may be obtained from the New York State Department of Health.

b.THE DOCUMENT MUST INCLUDE SUFFICIENT INFORMATION TO IDENTIFY THE DEATH CERTIFICATE TO BE CORRECTED.

c.THE DOCUMENT MUST VERIFY THE INFORMATION TO BE CORRECTED. (If the age of the deceased is incorrect, the document must show the correct date of birth; if the birthplace, the document must show the correct place of birth, etc.)

d.A DOCUMENT WHICH HAS BEEN ALTERED CANNOT BE ACCEPTED as proof for a correction.

Instructions to Registrar: If this form is returned to you satisfactorily completed, with appropriate documentary evidence (if required), you may enter the correction on the local record and issue copies immediately. Sign the bottom of the form and send it, with the documentary evidence, to the State Health Department so the original certificate may also be corrected. If you wish to have the correction form and evidence reviewed before you amend the local record, do not sign the bottom of the form but send it directly to the State Health Department. In this case, we will review the form and notify you as to whether or not the original certificate and your local record should be amended.

DOH-299 (6/99) Page 2 of 2