Application for Correction of Certificate of Death

NEW YORK STATE DEPARTMENT OF HEALTH

Vital Records Section

Application for Correction

of Certificate of Death

See Reverse Side for Instructions

Deceased

District Number

Date of Death

Place of Death

State Number

(name of applicant)

of _

(address of applicant)

request that the following information amend the certificate of death identified above:

ITEM IN ERROR

(or om itted)

AS IT APPEARS

AS IT SHOULD BE

Documentary evidence submitted herewith in support of this application includes:

Explain reason for error or omission:

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Under the penalties of pe~ury, I hereby affirm that the statements made herein are true and correct to the best of my knowledge.

Signature of Applicant Relationship to Deceased

Date

"" "" ,.,,,,,.,.,.,,,,,.,.,.,,,,,.,.,.,,,, ,,,,

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,.,.,.

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The above information has been added to the local record of death on file in this office.

Signature of Registrar

DOH-299 (6/99) Page 1 of 2

District Number Date

(OVER)

Purpose

Signature

Instructions for Completing Correction Form

This form may be used to correct information entered in error or to add information omitted at the

time the original death certificate was filed. Any other change or alteration of information on a

death certificate cannot be made without a court order

This form should be completed and signed by:

1. The physician who signed the original death certificate.

2. The individual who furnished the information for the original certificate.

Documentary 1.

Evidence

Documentary evidence IS NOT REQUIRED for the following changes:

a. ADDITION OF INFORMATION which was not available at the time the death certificate was

originally filed.

b. MINOR CHANGES IN SPELLING OF GIVEN NAME OR SURNAME of deceased or parents

(such as Smith to Smyth, Myer to Meyer, Bob to Robert, Jack to John, etc.). Any significant

change in name or spelling of name must be documented, per instructions below.

c. A CHANGE OF ONE YEAR OR LESS IN DATE OF BIRTH OF DECEASED.

Documentation is required for a change of more than one year.

2. Documentary evidence IS REQUIRED for all other corrections and must be submitted with

this form.

a. DOCUMENTS NORMALLY ACCEPTED AS PROOF FOR A CORRECTION ARE: birth

certificate of deceased, marriage record, church or synagogue record, physician's office

record, census record. A detailed listing of documents is enclosed, or may be obtained

from the New York State Department of Health.

b. THE DOCUMENT MUST INCLUDE SUFFICIENT INFORMATION TO IDENTIFY THE

DEATH CERTIFICATE TO BE CORRECTED.

c. THE DOCUMENT MUST VERIFY THE INFORMATION TO BE CORRECTED. (If the age

of the deceased is incorrect, the document must show the correct date of birth; if the

birthplace, the document must show the correct place of birth, etc.)

d. A DOCUMENT WHICH HAS BEEN ALTERED CANNOT BE ACCEPTED as proof for a

correction.

Return to:

Correction Unit

Vital Records Section

P.O. Box 2602

Albany, NY 12220-2602

Registrar of Vital Statistics

(for your local area)

Instructions to Registrar: If this form is returned to you satisfactorily completed, with appropriate documentary evidence (if

required), you may enter the correction on the local record and issue copies immediately. Sign the bottom of the form and send it,

with the documentary evidence, to the State Health Department so the original certificate may also be corrected. If you wish to

have the correction form and evidence reviewed before you amend the local record, do not sign the bottom of the form but send it

directly to the State Health Department. In this case, we will review the form and notify you as to whether or not the original

certificate and your local record should be amended.

DOH-299 (6/99) Page 2 of 2