Death Certificate Application

Register to vote: voting.
nyc
To order death certificates quickly and securely online through

VitalChek, visit nyc.gov/vitalrecords and click on ORDER
A DEATH CERTIFICATE ONLINE at the top of the page.
Office of Vital Records
125 Worth Street, CN-4, Room 119 To check the status of your order (newborn certificate,
New York, NY 10013-4090 birth certificate, death certificate, or birth or death certificate
correction), visit https://a816-evital.nyc.gov/eVitalVRRTS/.
SEE INSTRUCTIONS AND APPLICABLE FEES
BELOW AND ON THE SECOND PAGE.
DEATH 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 AT TIME OF DEATH 2. FIRST NAME 3. □

FEMALE
□ MALE □ X*
4. DATE OF DEATH 5. IF YOU DO NOT KNOW THE EXACT DATE OF DEATH

SEE BELOW
BEGIN END FOR FEE
SEARCH SEARCH INFORMATION
MM DD YYYY MM DD YYYY MM DD YYYY
6. PLACE OF DEATH 7. BOROUGH 8. AGE 9. H
OW MANY 10. DO YOU NEED A LETTER
□ MANH □ BRONX □ BKLYN □ QUEENS □ SI COPIES DO
YOU NEED?
OF EXEMPLIFICATION?
□ YES □ NO
11. SPOUSE OR DOMESTIC PARTNER’S NAME 12. LAST KNOWN ADDRESS 13. OCCUPATION OF DECEASED
14. FATHER/PARENT’S NAME BEFORE FIRST MARRIAGE 15. MOTHER/PARENTʼS NAME BEFORE FIRST MARRIAGE (MAIDEN NAME)
16. SOCIAL SECURITY NUMBER 17. CERTIFICATE NUMBER (if known)
18. WHY DO YOU NEED THIS CERTIFICATE? 19. WHAT IS YOUR RELATIONSHIP TO THE DECEASED?
CLEARLY PRINT YOUR MAILING AND CONTACT INFORMATION BELOW.

NAME
DAYTIME
PHONE -
NUMBER Area Code Telephone Number
STREET ADDRESS APT. NO.
EMAIL
CITY STATE ZIP CODE
ADDRESS
20. DO YOU NEED THE CAUSE OF DEATH? □ YES □ NO 21. FEES
You may only obtain cause of death if your relationship to the deceased $15 per copy x copies (maximum of 3) = $
is listed below. Please check the appropriate box. Cost of certified copy includes a two-consecutive-year search
□ Spouse or Domestic Partner □ Parent or Child □ Sibling $3 for each extra year searched x years = $
Total Amount Enclosed
□ Grandparent □ Grandchild (sum of the two $ amounts above): $
□ Person in control of disposition on death certificate FOR NOTARY PUBLIC USE ONLY
22. CUSTOMER SIGNATURE. IF BY MAIL, MUST BE NOTARIZED APPLICATIONS SUBMITTED BY MAIL MUST NOTARY PUBLIC SEAL
BE NOTARIZED
By my signature below, I state I am the person whom I represent myself to
be herein. I affirm the information within this form is complete and accurate. STATE OF
In addition, I acknowledge that misstating my identity or assuming the COUNTY OF

identity of another person 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

Signature (required) Date
NOTARY PUBLIC SIGNATURE
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 outside the U.S., send an international money order or check drawn on a U.S. bank. Cash is not accepted by mail or in person.
ORDER DEATH CERTIFICATES ONLINE QUICKLY AND SECURELY AT NYC.GOV/VITALRECORDS
*X is a gender that is not exclusively male or female (a nonbinary gender identity).
VR 66 (Rev. 6/22)
IMPORTANT DEATH CERTIFICATE INFORMATION
Relationship Death Certificate and Cause of Death Death Certificate Only
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.
• In Person: To make your request in person, you need to schedule an appointment online at
https://wb-nycdohmh.qmatic.cloud/qmaticwebbooking.
If you are unable to schedule an appointment and have an emergency request related to health care coverage,
government services, military, housing or employment, email nycdohvr@health.nyc.gov or call 311.
The office is at 125 Worth Street in Manhattan and is open Monday through Friday, 9 a.m. to 3:30 p.m. Use the
Lafayette Street (handicapped accessible) or Centre Street entrances. Please see identification requirements below.
• 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, Room 119, 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 for customers 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 and 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
• IDNYC Municipal ID • NYC MTA reduced fare card
• Permanent resident card • Military ID card
• University or college ID with a current transcript
If you do not have any of the above, we also accept:
• Two different documents dated within the past 60 days, if they show your name and address (we will mail you
the certificate):
– Utility or telephone bills (online bills can be downloaded from your provider)
– 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, if you are a party with a property right to protect or assert, or if you
can specify another judicial or other proper purpose. Documentation includes:
• Insurance policy • Bank book or statement • Other document showing entitlement
• Will • Property deed
If you are unable to provide the required documents, call 311 and ask for Vital Records assistance or email
nycdohvr@health.nyc.gov. If outside of NYC, call 212-639-9675.
VR 66 (Rev. 6/22)

Death Certificate Application

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Register to vote: voting.

To order death certificates quickly and securely online through

DEATH CERTIFICATE APPLICATION

1. LAST NAME AT TIME OF DEATH 2. FIRST NAME 3. □

4. DATE OF DEATH 5. IF YOU DO NOT KNOW THE EXACT DATE OF DEATH

16. SOCIAL SECURITY NUMBER 17. CERTIFICATE NUMBER (if known)

CLEARLY PRINT YOUR MAILING AND CONTACT INFORMATION BELOW.

20. DO YOU NEED THE CAUSE OF DEATH? □ YES □ NO 21. FEES

In addition, I acknowledge that misstating my identity or assuming the COUNTY OF

3 Ways to Order a New York City Death Certificate

Documentation requirements for applicants NOT related to the deceased

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