VR 66 (Rev. 12.23)
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 [email protected] 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
[email protected]. If outside of NYC, call 212-639-9675.
1. LAST NAME AT TIME OF DEATH 2. FIRST NAME
3. FEMALE
MALE X*
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?
11. SPOUSE OR DOMESTIC PARTNER’S NAME 12. LAST KNOWN ADDRESS 13. OCCUPATION OF DECEASED
NAME
STREET ADDRESS APT. NO.
CITY STATE ZIP CODE
DAYTIME
PHONE
NUMBER
Area Code Telephone Number
EMAIL
ADDRESS
CLEARLY PRINT YOUR MAILING AND CONTACT INFORMATION BELOW.
DEATH CERTIFICATE APPLICATION
(Please print clearly and ll 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 ll out the English form in English.)
4. DATE OF DEATH
MM DD YYYY
5. IF YOU DO NOT KNOW THE EXACT DATE OF DEATH
SEE BELOW
FOR FEE
INFORMATION
BEGIN
SEARCH
MM DD YYYY
END
SEARCH
MM DD YYYY
22. CUSTOMER SIGNATURE. IF BY MAIL, MUST 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.
In addition, I acknowledge that misstating my identity or assuming the
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.
Signature (required) Date
FOR NOTARY PUBLIC USE ONLY
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
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. 12.23)
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.
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/.
6. PLACE OF DEATH 7. BOROUGH
MANH BRONX BKLYN QUEENS SI
8. AGE 9. HOW MANY
COPIES DO
YOU NEED?
10. DO YOU NEED A LETTER
OF EXEMPLIFICATION?
YES NO
20. DO YOU NEED THE CAUSE OF DEATH? YES NO
You may only obtain cause of death if your relationship to the deceased
is listed below. Please check the appropriate box.
Spouse or Domestic Partner Parent or Child Sibling
Grandparent Grandchild
Person in control of disposition on death certificate
21. FEES
$15 per copy x copies = $
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): $
Oce of Vital Records
125 W
orth Street, CN-4, Room 119
New York, NY 10013-4090
SEE INSTRUCTIONS AND APPLICABLE FEES
BELOW AND ON THE FIRST PAGE.
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