Application to Local Registrar

for Copy of Death Record

Donna Lent, Town Clerk TC-02 Supplement B
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738 (631)
451-9101 FAX: 451-9264

Notarized Authorization for a Third-Party to Obtain a Death Certificate

I, _______________________, hereby authorize ___________________________ to obtain _____ copy(ies) of

the following death certificate:

Decedent’s Name: _____________________________

Date of Death: _____________________________
Place of Death: _____________________________
My Relationship to Decedent: ____________________________

___________________________ ____________________
Signed Phone1Xmber

___________________________
Date

STATE OF ___________________

COUNTY OF _________________

On the _____ day of _______________ in the year ________, before me, the undersigned, personally appeared
______________________ proved to me on the basis of satisfactory evidence to be the individual whose name
is subscribed to the within instrument and acknowledge that he executed the same in his capacity, and that by
his signature on the instrument, the individual, or the person upon behalf of which the individual acted,
executed the instrument.

_______________________________
Notary Public

TC-02 Supplement B (1/14) Page 1of 1