Form VR67 "Birth Certificate Application" - New York City

What Is Form VR67?

This is a legal form that was released by the New York City Department of Health and Mental Hygiene - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the New York City Department of Health and Mental Hygiene;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form VR67 by clicking the link below or browse more documents and templates provided by the New York City Department of Health and Mental Hygiene.

ADVERTISEMENT
ADVERTISEMENT

Download Form VR67 "Birth Certificate Application" - New York City

896 times
Rate (4.5 / 5) 43 votes
Register to vote:
http://www.nyccfb.info/public/VRC/registeringToVote.aspx?sm=public rtv
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
BIRTH CERTIFICATE APPLICATION
(Please Print Clearly)
1. LAST NAME ON BIRTH CERTIFICATE
2. FIRST NAME
[]
3.
FEMALE
[]
[]
MALE
X
4a. IF YOU KNOW THE EXACT DATE OF BIRTH
4b. IF YOU DON’T KNOW THE EXACT DATE OF BIRTH
SEE BELOW
BEGIN
END
FOR FEE
SEARCH
SEARCH
INFORMATION
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
5. NAME OF HOSPITAL OR ADDRESS WHERE BORN
6. BOROUGH WHERE BORN
0
0
0
0
0
MAN
BRONX
BKLYN
QUEENS
SI
7. MOTHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE (MAIDEN NAME):
8. BIRTH CERTIFICATE NUMBER (if known)
FIRST
LAST
9. FATHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE
10. WHY DO YOU NEED THIS BIRTH CERTIFICATE
FIRST
LAST
11. DO YOU NEED A LETTER
12. HOW MANY COPIES
13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE?
OF EXEMPLIFICATION?
DO YOU NEED?
SELF/PARENT/OTHER (please explain)
0
0
0
0
0
YES
NO
1
2
3
PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
NAME
DAYTIME
PHONE
NUMBER
Area Code
Telephone Number
STREET ADDRESS
APT. NO.
E-MAIL
CITY
STATE
ZIP CODE
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
NOTARY PUBLIC SEAL
FEES
BE NOTARIZED
copies
$
$15 per copy x
STATE OF
Cost of certified copy includes a two consecutive
year search
COUNTY OF
years $
$3 for each extra year searched x
SUBSCRIBED AND SWORN BEFORE ME:
Total Amount Enclosed: $
THIS
DAY OF
, 20
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED.
CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.
NOTARY PUBLIC SIGNATURE
ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT WWW.NYC.GOV/VITALRECORDS
VR 67 (Rev. 10/14)
Register to vote:
http://www.nyccfb.info/public/VRC/registeringToVote.aspx?sm=public rtv
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
BIRTH CERTIFICATE APPLICATION
(Please Print Clearly)
1. LAST NAME ON BIRTH CERTIFICATE
2. FIRST NAME
[]
3.
FEMALE
[]
[]
MALE
X
4a. IF YOU KNOW THE EXACT DATE OF BIRTH
4b. IF YOU DON’T KNOW THE EXACT DATE OF BIRTH
SEE BELOW
BEGIN
END
FOR FEE
SEARCH
SEARCH
INFORMATION
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
5. NAME OF HOSPITAL OR ADDRESS WHERE BORN
6. BOROUGH WHERE BORN
0
0
0
0
0
MAN
BRONX
BKLYN
QUEENS
SI
7. MOTHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE (MAIDEN NAME):
8. BIRTH CERTIFICATE NUMBER (if known)
FIRST
LAST
9. FATHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE
10. WHY DO YOU NEED THIS BIRTH CERTIFICATE
FIRST
LAST
11. DO YOU NEED A LETTER
12. HOW MANY COPIES
13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE?
OF EXEMPLIFICATION?
DO YOU NEED?
SELF/PARENT/OTHER (please explain)
0
0
0
0
0
YES
NO
1
2
3
PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
NAME
DAYTIME
PHONE
NUMBER
Area Code
Telephone Number
STREET ADDRESS
APT. NO.
E-MAIL
CITY
STATE
ZIP CODE
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
NOTARY PUBLIC SEAL
FEES
BE NOTARIZED
copies
$
$15 per copy x
STATE OF
Cost of certified copy includes a two consecutive
year search
COUNTY OF
years $
$3 for each extra year searched x
SUBSCRIBED AND SWORN BEFORE ME:
Total Amount Enclosed: $
THIS
DAY OF
, 20
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED.
CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.
NOTARY PUBLIC SIGNATURE
ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT WWW.NYC.GOV/VITALRECORDS
VR 67 (Rev. 10/14)
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.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. If from a foreign country, send an international money order.
Check current times at www.nyc.gov/vitalrecords.
3 WAYS TO ORDER A NEW YORK CITY BIRTH CERTIFICATE
Online: Visit www.nyc.gov/vitalrecords to order using a credit card, debit card, or electronic check.
l
Online orders are processed within 24 hours on weekdays, and UPS express mail delivery is available.
Walk-In: Go to 125 Worth Street in Lower Manhattan and use the Lafayette Street (handicapped accessible) or
l
Centre Street entrances. We are open Monday through Friday 9:00
– 3:30
. Lines are shortest in the morning.
AM
PM
Please see identification requirements below.
By Mail: All mailed applications must be notarized. Mail your application to 125 Worth Street, CN-4, New York,
l
NY 10013. Be sure to include a self-addressed, stamped, envelope with your check or money order payable
to the NYC Department of Health and Mental Hygiene. You must provide a photocopy of Category 1
identification or original copies of identification from Category 2 (see below).
Identification (ID) Requirements to get a Birth Certificate for you or your child.
Category 1: Identity documents. If you order in person you can leave with your short form certificate in most
cases, unless you require a long form certificate.
Provide any of the following, if it includes your photo, your signature and is unexpired:
Driver’s License or non-driver’s ID from any state or U.S. territory
l
Public benefit card
l
U.S. or foreign passport
l
U.S. certificate of naturalization
l
Military ID card
l
Employee ID with photo, verifiable employer and recent pay stub
l
MTA reduced-fare Metro Card
l
Student ID and current transcript from accredited and verifiable institution
l
Inmate photo ID with release papers
l
Category 2: Proof of address. If you do not have any of the above, you may provide proof of address as described
below. Your certificate will be mailed to address on documents provided.
Two different documents dated within the past 60 days, if they show your name and address
Utility bills (online bills can be downloaded from your provider)
l
Letter from a government agency
l
If you cannot provide Category 1 or 2 identification, please contact Vital Records at nycdohvr@health.nyc.gov.
VR 67 (Rev. 10/14)
Page of 2