"Death Certificate Application" - New York City (English/Chinese Simplified)

Death Certificate Application is a legal document that was released by the New York City Department of Health and Mental Hygiene - a government authority operating within New York City.

Form Details:

  • Released on December 1, 2019;
  • The latest edition currently provided by the New York City Department of Health and Mental Hygiene;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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人口统计处 (Office of Vital Records)
125 Worth Street, CN-4, Room 133
New York, N.Y. 10013-4090
:
如需快速安全地申请死亡证明,请访问
nyc.gov/vitalrecords
voting.nyc
登记投票:
请参见下方及背面的说明和适用费用
SEE INSTRUCTIONS AND
APPLICABLE FEES BELOW AND
ON BACK
死亡证明申请
DEATH CERTIFICATE APPLICATION
(请用英文正楷填写尽可能多的信息。递交用其他语言填写的申请表可能需要较长的时间来处理。)
(Please print clearly and fill out as much information in English as you can. Forms submitted in other languages might take longer to process.)
O
1. 死亡时的姓氏 / LAST NAME AT TIME OF DEATH
2. 名字 / FIRST NAME
3.
女性 / FEMALE
O
男性 / MALE
O
X
4. 死亡日期 /
DATE OF DEATH
5. 如果您不知道具体的死亡日期 /
IF YOU DON’T KNOW THE EXACT DATE OF DEATH
开始搜索
结束搜索
BEGIN
END
SEARCH
SEARCH
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
6.
死亡地 / PLACE OF DEATH
7.
行政区 / BOROUGH
8. 年龄 /
9. 您需要几份副本?/ HOW
10. 您是否需要示例信函?/ DO YOU
O
O
O
O
O
AGE
MANY COPIES DO YOU
NEED A LETTER OF
曼哈顿
布朗士
布鲁克林
皇后区
史丹顿岛
NEED?
EXEMPLIFICATION
O
O
O
O
O
MAN
BRONX
BKLYN
QUEENS
SI
O
O
是 / YES
否 / NO
11. 配偶或同居伴侣姓名 / SPOUSE OR DOMESTIC
12. 最新地址 / LAST KNOWN ADDRESS
13. 死亡时的职业 / OCCUPATION OF DECEASED
PARTNER’S NAME
14. 父亲 / 家长姓名 / FATHER / PARENT’S NAME
15. 母亲 / 家长婚前姓名 / MOTHER / PARENT’S NAME BEFORE MARRIAGE
(if known)
16. 社会安全号码 / SOCIAL SECURITY NUMBER
17. 证明编号
/ CERTIFICATE NUMBER
(如果知道)
18. 您为什么需要这份证明? / WHY DO YOU NEED THIS CERTIFICATE?
19. 您和已故者是什么关系? / WHAT IS YOUR RELATIONSHIP TO DECEASED?
请在下方用英文正楷填写您的邮寄和联系信息 / PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
姓名 / NAME
日间联系电话 / DAYTIME PHONE
区号 / Area Code 电话号码 / Telephone Number
街道地址 / STREET ADDRESS
公寓编号 / APT. NO.
NUMBER
市 / CITY
州 / STATE
邮编 / ZIP CODE
电子邮箱地址 / E-MAIL ADDRESS
20. 您是否需要死亡原因? / DO YOU NEED THE CAUSE OF DEATH?
21.
费用 / FEES
O
O
是 / YES
否 / NO
15 x
___
美元
份数
美元
$15 per copy x copies
只有当您与已故者的关系如下方所列才可获得死亡原因:
You may only obtain cause of death if your relationship to the deceased is
认证副本费用包括一项连续两年的搜索费用
listed below:
Cost of certified copy includes a two consecutive year search
请勾选相应框 / Please check the appropriate box
超过两年的搜索费用为 3
x
___
美元
年限
美元
O
配偶或同居伴侣 / Spouse or Domestic Partner
$3 for each extra year searched x years
O
O
父母或子女 / Parent or Child
兄弟姐妹 / Sibling
___
随附总额
美元
O
O
祖父母 / Grandparent
孙子女 / Grandchild
Total Amount Enclosed:
O
负责处理死亡证明的人员 / Person in control of disposition on death
如果记录未存档,将发放经核证的“NOT FOUND STATEMENT”(“未找到记录声明”)
certificate
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT” WILL BE
ISSUED
1
(Rev. 12/19) (Simplified Chinese)
人口统计处 (Office of Vital Records)
125 Worth Street, CN-4, Room 133
New York, N.Y. 10013-4090
:
如需快速安全地申请死亡证明,请访问
nyc.gov/vitalrecords
voting.nyc
登记投票:
请参见下方及背面的说明和适用费用
SEE INSTRUCTIONS AND
APPLICABLE FEES BELOW AND
ON BACK
死亡证明申请
DEATH CERTIFICATE APPLICATION
(请用英文正楷填写尽可能多的信息。递交用其他语言填写的申请表可能需要较长的时间来处理。)
(Please print clearly and fill out as much information in English as you can. Forms submitted in other languages might take longer to process.)
O
1. 死亡时的姓氏 / LAST NAME AT TIME OF DEATH
2. 名字 / FIRST NAME
3.
女性 / FEMALE
O
男性 / MALE
O
X
4. 死亡日期 /
DATE OF DEATH
5. 如果您不知道具体的死亡日期 /
IF YOU DON’T KNOW THE EXACT DATE OF DEATH
开始搜索
结束搜索
BEGIN
END
SEARCH
SEARCH
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
6.
死亡地 / PLACE OF DEATH
7.
行政区 / BOROUGH
8. 年龄 /
9. 您需要几份副本?/ HOW
10. 您是否需要示例信函?/ DO YOU
O
O
O
O
O
AGE
MANY COPIES DO YOU
NEED A LETTER OF
曼哈顿
布朗士
布鲁克林
皇后区
史丹顿岛
NEED?
EXEMPLIFICATION
O
O
O
O
O
MAN
BRONX
BKLYN
QUEENS
SI
O
O
是 / YES
否 / NO
11. 配偶或同居伴侣姓名 / SPOUSE OR DOMESTIC
12. 最新地址 / LAST KNOWN ADDRESS
13. 死亡时的职业 / OCCUPATION OF DECEASED
PARTNER’S NAME
14. 父亲 / 家长姓名 / FATHER / PARENT’S NAME
15. 母亲 / 家长婚前姓名 / MOTHER / PARENT’S NAME BEFORE MARRIAGE
(if known)
16. 社会安全号码 / SOCIAL SECURITY NUMBER
17. 证明编号
/ CERTIFICATE NUMBER
(如果知道)
18. 您为什么需要这份证明? / WHY DO YOU NEED THIS CERTIFICATE?
19. 您和已故者是什么关系? / WHAT IS YOUR RELATIONSHIP TO DECEASED?
请在下方用英文正楷填写您的邮寄和联系信息 / PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
姓名 / NAME
日间联系电话 / DAYTIME PHONE
区号 / Area Code 电话号码 / Telephone Number
街道地址 / STREET ADDRESS
公寓编号 / APT. NO.
NUMBER
市 / CITY
州 / STATE
邮编 / ZIP CODE
电子邮箱地址 / E-MAIL ADDRESS
20. 您是否需要死亡原因? / DO YOU NEED THE CAUSE OF DEATH?
21.
费用 / FEES
O
O
是 / YES
否 / NO
15 x
___
美元
份数
美元
$15 per copy x copies
只有当您与已故者的关系如下方所列才可获得死亡原因:
You may only obtain cause of death if your relationship to the deceased is
认证副本费用包括一项连续两年的搜索费用
listed below:
Cost of certified copy includes a two consecutive year search
请勾选相应框 / Please check the appropriate box
超过两年的搜索费用为 3
x
___
美元
年限
美元
O
配偶或同居伴侣 / Spouse or Domestic Partner
$3 for each extra year searched x years
O
O
父母或子女 / Parent or Child
兄弟姐妹 / Sibling
___
随附总额
美元
O
O
祖父母 / Grandparent
孙子女 / Grandchild
Total Amount Enclosed:
O
负责处理死亡证明的人员 / Person in control of disposition on death
如果记录未存档,将发放经核证的“NOT FOUND STATEMENT”(“未找到记录声明”)
certificate
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT” WILL BE
ISSUED
1
(Rev. 12/19) (Simplified Chinese)
FOR NOTARY PUBLIC USE ONLY
22. 客户签名。通过邮寄方式提交的签名必须经过公证
CUSTOMER SIGNATURE. IF BY MAIL MUST BE NOTARIZED
(仅用于公证)
通过在下方签名,我声明我是代表我本人的个人。我确认此表格中的信息完整而准
APPLICATIONS SUBMITTED BY MAIL
NOTARY PUBLIC SEAL
确。此外,我认可如果伪报我的身份或冒充其他人的身份(包括伪造签名)将属轻
MUST BE NOTARIZED
罪,违反者同时将处以最高达 2,000 美元的罚款。
By my signature below, I state I am the person whom I represent myself to be herein.
STATE OF
I affirm the information within this form is complete and accurate. In addition, I
acknowledge that misstating my identity or assuming the identity of another person
COUNTY OF
including forging a signature may subject me to a misdemeanor and violators may
also be subject to a fine of up to $2,000.
SUBSCRIBED AND SWORN BEFORE ME:
THIS
DAY OF
, 20
签名(必需)
日期
Signature (required)
Date
NOTARY PUBLIC SIGNATURE
邮寄申请不接受信用卡付款。请以支票或汇票方式(抬头为 “NYC Department of Health and Mental Hygiene”)进行支付。如果您来自其他国家,请寄送
一张以一家美国银行为付款人的国际汇票或支票。不接受邮寄或面交现金。
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.
如需快速安全地申请死亡证明,请访问 NYC.GOV/VITALRECORDS
ORDER DEATH CERTIFICATES QUICKLY AND SECURELY AT NYC.GOV / VITALRECORDS
(Rev. 12/19) (Simplified Chinese)
2
关于死亡证明的重要信息
死亡证明 + 死亡原因
关系
仅死亡证明
配偶、同居伴侣、父母、子女、兄弟
姐妹、祖父母、孙子女
侄女/外甥女、侄子/外甥、姨妈/姑
妈、姑父/姨父、曾孙、玄孙、侄孙
女/甥孙女、侄孙/甥孙
为获取死亡证明而篡改信息(包括伪造签名)属轻罪,违反者每次将处以最高达 2,000 美元的罚款。
提交假冒身份属于犯罪,将对违反者提起诉讼。
请见下方身份要求、费用和其他重要信息。
ID 要求可能会有变更。
申请纽约市死亡证明的 3 种方式
在线:访问 nyc.gov/vitalrecords ,使用信用卡、借记卡或电子支票进行订购。“只有配偶、非婚姻同居伴侣、
父母、兄弟姐妹、祖父母、孙子女或负责处理死亡证明的人员(提供资料的人员)才可在线提交订单”。
来访:前往位于下曼哈顿区的 125 Worth Street,从 Lafayette Street(无障碍通道)或 Centre Street 入口进入。
我们的工作时间为周一至周五上午 9:00 至下午 3:30。早上排队的人最少。
邮寄:通过邮寄提交的申请必须在公证人员面前进行签名。请将您的申请邮寄至 125 Worth Street, CN-4, New
York, NY 10013。请务必将支付的支票或汇票(抬头为 “NYC Department of Health and Mental Hygiene”)与
一枚贴上邮票的回邮信封一同寄送给我们。您必须提供第 1 类身份证明的复印件或 2 类身份证明的原件副本
(参见下文)
已故者的配偶、同居伴侣、父母、兄弟姐妹、祖父母、孙子女,或负责处理死亡证明的人员(提供资料的人
员)申请死亡证明时的身份证明(ID)要求
前提是
我们接受以下任意身份证明,
其中包含您的照片和签名且未过期:
• 驾驶证或非驾驶员的身份证
• 服刑人员身份证及最近释放文件
• 带照片的 NYS 保障卡
• 工作证及最近工资存根
• NYC 残障专车 (Access-A-Ride) 卡
• 美国或外国护照或护照卡
• 永久居民卡
• IDNYC 市民身份证
• NYC MTA 优惠地铁卡
• 大学或学院学生证及最近成绩单
如果您无法提供上述资料,我们也可接受:
下方注明的两类不同文件显示您的姓名和地址,前提是文件日期在过去 60
天以内,且我们将以邮寄方
式发放死亡证明
水电或电话账单
o
您收到的政府官方邮寄资料
o
与已故者无关联的申请人的文件要求
如果您与已故者无关联,需确认您有权利获取其死亡证明。如果您是房产的法定代理人、保护或维护不动产权的一方,
或您可说明其他司法或其他合法用途,可获得死亡证明。
保单
遗嘱
银行存折或对账单
房产契据
其他能证明您权利的文件
如果您无法提供所要求的文件,请致电 311 或 1-212-639-9675(如果您不在纽约市)向我们求助。
(Rev. 12/19) (Simplified Chinese)
3
IMPORTANT DEATH CERTIFICATE INFORMATION
Relationship
Death Certificate + Cause of
Death Certificate Only
Death
Spouse, Domestic Partner, Parent,
Child, Sibling, Grandparent,
Grandchild
Niece, Nephew, Aunt, Uncle, Great
Grandchild, Great-Great Grandchild,
Grandniece, Grandnephew
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 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 9:00
– 3:30
. Lines are shortest in the
AM
PM
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 payable to the NYC Department of Health and Mental Hygiene.
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
Inmate ID with current release papers
• NYS benefit card with photo
Job ID with a current pay stub
• U.S. or foreign passport or passport card
NYC Access-A-Ride card
• Permanent resident card
IDNYC Municipal ID
• University or college ID with a current transcript
NYC MTA reduced fare card
If you don’t have any of the above, we also accept:
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
o
Utility or telephone bills
o
Official government mail that you have received
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 1-212-639-9675 if you are
outside of New York City.
4
(Rev. 12/19) (Simplified Chinese)
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