This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

---

THE CITY OF NEW YORK - DEPARTMENT OF HEALTH
BUREAU OF VITAL RECORDS 125 Worth Stroot New York, N.Y. 10013
APPLICATION FOR A BIRTH RECORD
(Print All Items Clearly)
LAST NAME ON BIRTH RECORD			F I RST NAME		| | FEMALE j | MALE
DATE OF BIRTH Month Day Year		PLACE OF BIRTH (NAME OF HOSPITAL, OR IF AT HOME, NO. AND STREET)			BOROUGH OF BIRTH
MOTHER'S MAIDEN NAME (Name Before Marriage) FIRST LAST				CERTIFICATE NUMBER IF KNOWN	
FATHER'S NAME FIRST LAST				For Office Use Only	
NO. OF COPIES	YOUR RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD. IF SELF, STATE "SELF"				
FOR WHAT PURPOSE ARE YOU GOING TO USE THIS BIRTH RECORD					
NOTE: Copy of a birth record can be issued only to persons to whom the record of birth relates, if of age, or a parent or other lawful representative. IF THIS REQUEST IS NOT FOR YOUR OWN BIRTH RECORD OR THAT OF YOUR CHILD, NOTARIZED AUTHORIZATION FROM THE PARENT OR THE PERSON NAMED ON THE CERTIFICATE MUST BE PRESENTED WITH THIS APPLICATION.					
Section 3.19, New York City Health Code provides, in part:”. . . no person shall make a false, untrue or misleading statement or forge the signature of another on a certificate, application, registration, report or other document required to be prepared pursuant to this Codo." Section 558 (d) of the New York City Charter provides that any violation of tho Health Code shell be treated and punished os a misdemeanor.					
FEES
SEARCH FOR TWO CONSECUTIVE YEARS AND ONE COPY OR A CERTIFIED ’ NOT FOUND STATEMENT"
EACH ADDITIONAL COPY REQUESTED...................................................................
E ACH EXTRA YEAR SEARCHED (WITH THIS APPLICATION).......................
1. Make chock or money order payable to: Department of Health, N.Y.C.
3. If from a foreign country, send an international monoy ordor or a chock drawn on a U.S. bank.
3. Stamps or foreign currency will not bo accepted. CASH NOT ACCEPTED BY MAIL.
NOTE: PLEASE ATTACH A STAMPED SELF-ADDRESSED ENVELOPE.
FOR OFFICE USE ONL Y
SEARCH RESULTS^	REPORTED BY □ CRT □ MANUAL INITIAL ^	CERTIFICATE NUMBER		LAST NAME - 4 LETTERS		DATE OF BIRTH
					1	i i * i
READING DATE			DATE ISSUED: BY MAIL		DATE ISSUED: IN PERSON	
VR-67 (Rev. 10/82)