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MUNICIPAL ARCHIVES
Department of Records and Information Services
3	1 Chnmbcrs Street New York, N.Y. 10007
(212) 566-5292
IDILIO GRACIA I’F.NA. Director
APPLICATION FOR A COPY OF A BIRTH RECORD
	OFFICE USE ONLY
FEES	
DO tfOT SEND CASH	
Stamped, self-addressed envelope MUST be attached.	
Make chock or money order payable to:	
NYC DEPARTMENT OF RECORDS AND	
INFORMATION SERVICES	
Standard fee for the Issuance of a copy of	
a certificate based on a search of records	
when name, year and borough are accurately given.	
For each additional year to be searched.	
For each additional borjugh to be searched.	
For each additional copy of a certificate.	t
PLEASE PRINT OR TYPE
Last name at time of birth
First name
Date of birth/Year(s) to be searched Month	Day
Year(s)
Place of birth, please specify borough(s) to be searched
Father's name, if known
Mother's name. If known
Your relationship to person named above
No. copies requested
Your name, please print
Address
Signature
City
State
Zip Code
MA-22(5-85)