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To order birth certificates quickly and securely online through
VitalChek, visit nyc.gov/vitalrecords and click on ORDER
A BIRTH CERTIFICATE ONLINE at the top of the page.
To check the status of your order (newborn certificate,
birth certificate, death certificate, or birth or death certificate
correction), visit https://a816-evital.nyc.gov/eVitalVRRTS/.
Office of Vital Records
125 Worth Street, CN-4, Room 119
New York, NY 10013-4090
SEE INSTRUCTIONS AND APPLICABLE
FEES BELOW AND ON THE FIRST PAGE.
BIRTH CERTIFICATE APPLICATION
(Please print clearly and fill out as much information in English as you can. Forms submitted in other languages will take longer to process.
Translations of this form are available online for reference only — please fill out the English form in English.)
1. LAST NAME ON BIRTH CERTIFICATE 2. FIRST NAME
3.
□ FEMALE
□ MALE □ X*
5. NAME OF HOSPITAL OR ADDRESS WHERE BORN 6. BOROUGH WHERE BORN
□ MANH □ BRONX □ BKLYN □ QUEENS □ SI
7. MOTHER/PARENT’S NAME BEFORE FIRST MARRIAGE (MAIDEN NAME)
FIRST LAST
8. BIRTH CERTIFICATE NUMBER (if known)
9. FATHER/PARENT’S NAME BEFORE FIRST MARRIAGE
FIRST LAST
10. WHY DO YOU NEED THIS BIRTH CERTIFICATE?
11a. DO YOU NEED A LONG FORM
BIRTH CERTIFICATE?**
□ YES □ NO
11b. DO YOU NEED A LETTER
OF EXEMPLIFICATION?***
□ YES □ NO
12. HOW MANY COPIES
DO YOU NEED?
□ 1 □ 2 □ 3
13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH
CERTIFICATE? SELF/PARENT/OTHER (please explain)
NAME
STREET ADDRESS APT. NO.
CITY STATE ZIP CODE
DAYTIME
PHONE
NUMBER
EMAIL
ADDRESS
CLEARLY PRINT YOUR MAILING AND CONTACT INFORMATION BELOW.
-
Area Code Telephone Number
14. CUSTOMER SIGNATURE AND DATE
SIGNATURE:
DATE:
15. CUSTOMER COMMENTS/ADDITIONAL INFORMATION
NOTE: A copy of a birth record can be issued only to a person to whom the record of birth relates, if of age, or to a parent or human service
organization. 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.
4a. IF YOU KNOW THE EXACT DATE OF BIRTH 4b. IF YOU DO NOT KNOW THE EXACT DATE OF BIRTH
SEE BELOW
FOR FEE
INFORMATION
MM DD YYYY
BEGIN
SEARCH
MM DD YYYY
END
SEARCH
MM DD YYYY
FEES
$15 per copy x copies (maximum of 3) = $
Cost of certified copy includes a two-consecutive-year search
$3 for each extra year searched x
years = $
Total Amount Enclosed
(sum of the two $ amounts above): $
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED. CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.
CERTIFICATE REQUEST LIMIT: UP TO THREE.
APPLICATIONS SUBMITTED BY MAIL MUST
BE NOTARIZED
STATE OF
COUNTY OF
SUBSCRIBED AND SWORN BEFORE ME:
THIS DAY OF , 20
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC SEAL
ORDER BIRTH CERTIFICATES ONLINE QUICKLY AND SECURELY AT NYC.GOV/VITALRECORDS
*X is a gender that is not exclusively male or female (a nonbinary gender identity).
**A short form birth certificate can be used for most domestic purposes. It includes the child’s first and last names, date of birth, sex or gender marker, and the first and last names
of the mother/parent and father/parent. A long form birth certificate also includes the child’s place of birth and time of birth, the parents’ address and other information at the time
of birth, and information about the doctor who delivered the child.
***If you need a letter of exemplification, order a long form birth certificate.
VR 67 (Rev. 12.23)