APPLICATION FOR A CERTIFIED COPY OF DEATH RECORD BEFORE 1949

Fee: $10.00 per certified copy when certificate number is provided.

Enclose stamped, self-addressed envelope.

Make check or money order payable to NYC Dept. of Records & Information Services.

To expedite processing, please send each request separately with the requested fee and stamped self-addressed envelope.

PLEASE PRINT OR TYPE

Last name at time of death	First name			Middle name
Date of death Month Day Year		Cemetery, if known
Place of death		City/Borough			Age
Father’s name, if known		Mother’s name, if known
Your Relationship to deceased			Certificate number
Purpose for which record will be used			Number of copies requested
Your name (please print)		Signature
Address
City		State				Zip Code

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