Application to Town Clerk

for Copy of Birth Certificate

Donna Lent, Town Clerk TC-01 Supplement B rev. 1/14
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 Birth Certificate

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

the following birth certificate:

Birth Name: _____________________________

Date of Birth: _____________________________
Place of Birth: _____________________________
Mother’s Maiden Name: _____________________________
Father’s Name: _____________________________

I am the Parent/Person (circle one) named on the certificate.

___________________________ ____________________
Signed Phone Number

___________________________
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-01 Supplement B Page 1of 1