New York State Department of Health - Vital Records (death) · New York state form

DOH-4376 Mail-In Application for Copy of Death Certificate

Use DOH-4376 to request a death certificate for a death outside New York City. Applicants must provide identification and, when required, proof of lawful right or claim.

What this form is: The New York State Department of Health’s DOH-4376 is a mail-in application for a copy of a death certificate for a death that occurred in New York State outside New York City. The applicant completes and signs the form, includes required identification and any applicable documentation, and sends payment by check or money order. A notarized statement is required when the record is to be sent to a P.O. Box or third party.
Who needs it: People requesting a death certificate for a death outside New York City who are the deceased’s spouse, parent, child, or sibling, or can document a lawful right or claim.
Why it needs a notary: A notarized statement is required if the record will be delivered to a P.O. Box or third party. That statement can be notarized online with a commissioned online notary.
How to submit it: Mail the signed application, payment, required identification, and any required documentation to the Vital Records Certification Unit, P.O. Box 2602, Albany, NY 12220-2602.

Questions

Who can use the DOH-4376 application?

Use this application if the death occurred in New York State outside New York City and you are the deceased’s spouse, parent, child, or sibling. Other applicants must submit documentation establishing a lawful right or claim.

Is a notary needed for the DOH-4376 application?

A notarized statement signed by the applicant is required if the record is to be sent to a P.O. Box or third party. This can be done online with a commissioned online notary.

Where do I mail the completed application?

Mail the signed application and required materials to the New York State Department of Health, Vital Records Certification Unit, P.O. Box 2602, Albany, NY 12220-2602.