Nyc Health Form Vr 66 – Fill Out and Use This PDF

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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

DEATH CERTIFICATE APPLICATION

(Please Print Clearly)

1. LAST NAME AT TIME OF DEATH

2. FIRST NAME

3. ☐ FEMALE

☐ MALE

4. DATE OF DEATH

5. IF YOU DON’T KNOW THE EXACT DATE OF DEATH

BEGIN

END

SEARCH

SEARCH

MM

DD

YYYY

MM

DD

YYYY

MM

DD

YYYY

6. PLACE OF DEATH

7. BOROUGH

8. AGE

9. HOW MANY COPIES

10. DO YOU NEED A LETTER OF

MAN ☐ BRONX ☐ BKLYN ☐ QUEENS ☐ SI ☐

DO YOU NEED?

EXEMPLIFICATION ☐ YES ☐ NO

11. SPOUSE OR DOMESTIC PARTNER’S NAME

12. LAST KNOWN ADDRESS

13. OCCUPATION OF DECEASED

14. FATHER/PARENT’S NAME

/ʼ

16. SOCIAL SECURITY NUMBER

17. CERTIFICATE NUMBER (if known)

18. WHY DO YOU NEED THIS CERTIFICATE?

19. WHAT IS YOUR RELATIONSHIP TO DECEASED?

PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW

NAME

DAYTIME

PHONE

NUMBER

Area Code

Telephone Number

E-MAIL

ADDRESS

20. DO YOU NEED THE CAUSE OF DEATH? ☐ YES

☐ NO

21. FEES

You may only obtain cause of death if your relationship to the deceased is

$15 per copy x _________ copies

$ _________

listed below:

Cost of certified copy includes a two consecutive year search

Please check the appropriate box

☐ Spouse or Domestic Partner ☐ Parent or Child ☐ Sibling

$3 for each extra year searched x _______ years

$ _________

☐ Grandparent ☐ Grandchild

Total Amount Enclosed: $ _________

☐ Person in control of disposition on death certificate

IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT” WILL BE ISSUED.

APPLICATIONS SUBMITTED BY MAIL MUST

NOTARY PUBLIC SEAL

22. CUSTOMER SIGNATURE. IF BY MAIL MUST BE NOTARIZED

BE NOTARIZED

By my signature below, I state I am the person whom I represent myself to be

herein. I affirm the information within this form is complete and accurate. In

STATE OF

addition, I acknowledge that misstating my identity or assuming the identity of

another person including forging a signature may subject me to a misdemeanor

COUNTY OF

and violators may also be subject to a fine of up to $2,000.

SUBSCRIBED AND SWORN BEFORE ME:

THIS ______ DAY OF _______________ , 20 ____

Signature (required)

Date

NOTARY PUBLIC SIGNATURE

Credit cards are not accepted for mail-in orders. Please make your check or money order payable to the NYC Department of Health and Mental Hygiene. If from a foreign country, send an international money order or check drawn on a U.S. bank. Cash is not accepted by mail or in person.

ORDER DEATH CERTIFICATES QUICKLY AND SECURELY AT WWW.NYC.GOV/VITALRECORDS

VR 66 (Rev. 01/15)

IMPORTANT DEATH CERTIFICATE INFORMATION

‚You can obtain a death certificate if you are the spouse, domestic partner, parent, child, sibling, grandparent or grandchild of the decedent, or if you establish your right to obtain this document (see documentation requirements below).

‚All death certificates are mailed, usually within 2-4 weeks. If there is an urgent need, and documentation is provided, you can request expedited services and you will be called to pick up the certificate in 5-7 business days.

‚Falsifying information, including forging a signature, to obtain a death certificate is a misdemeanor and violators may also be subject to a fine of up to $2,000 per violation.

‚Submitting fraudulent identification is a crime and violators are subject to prosecution.

‚Please see below for identification requirements, fees and other important information.

‚ID requirements are subject to change.

3 WAYS TO ORDER A NEW YORK CITY DEATH CERTIFICATE

●Online: Visit www.nyc.gov/vitalrecords to order using a credit card, debit card or electronic check. “Only spouses, domestic partners, parent, siblings, grandparent, grandchild, or person in charge of the disposition (informant) may submit orders online”

●Walk-In: Go to 125 Worth Street in Lower Manhattan and use the Lafayette Street (handicapped accessible) or Centre Street entrances. We are open Monday through Friday 9:00AM – 3:30PM. Lines are shortest

in the morning.

●By Mail: Applications submitted by mail must be signed in the presence of a Notary Public. Mail your application to 125 Worth Street, CN-4, New York, NY 10013. Be sure to include a self-addressed, stamped, envelope with your check or money order. You also will need to provide a photocopy of the required identification and any necessary documentation (see below).

Identification (ID) Requirements including the deceased’s spouse, domestic partner, parent, sibling, grandparent, grandchild, or person in charge of the disposition (informant)

We accept any of the following, IF it includes your photo, your signature and is unexpired:

●Driver’s License or Non-driver’s ID Card

●IDNYC Municipal ID

●Passport

●Government ID

●Employment ID with pay stub

If you don’t have any of the above, we also accept:

●Inmate photo ID with release papers

●Two different documents as indicated below if they show your name and address and are dated within the past 60 days, we will MAIL the certificate

m Utility or telephone bills

m Official government mail that you have received

If you do not have the items required above, you may email nycdohvr@health.nyc.gov for additional information and options.

Documentation Requirements for applicants NOT related to the deceased

If you are not related to the deceased, you need to establish your right to obtain a death certificate. You may obtain a death certificate if you are the legal representative of the estate, a party with a property right to protect or assert, or if you can specify another judicial or other proper purpose.

●Insurance Policy

●Will

●Bank Book or statement

●Property Deed

●Other document showing entitlement

If you are unable to provide the required documents, ask us for help by calling 311 or 1-212-NEW-YORK if you are outside of New York City.

VR 66 (Rev. 01/15)