Office of the Village Clerk
243 Main Street, Johnson City, New York 13790
(607) 798-7861
Name of Deceased: (First, Middle, Last) _____________________________________________
Date of Death: _____________ SSN# of Deceased if Known: _________________________
Date of Birth of Deceased: _______________ Age at Death: _______________
Place of Death: (Hospital or residence)___________________________________________________
Village of Johnson City, Broome County, New York.Name of Father of Deceased: (First, Middle, Last)_____________________________________________
Maiden Name of Mother of Deceased: (First, Middle, Last)______________________________________
Number of copies requested ________________ (Fee: $10.00 per certificate or no record certification)
Purpose for which record is required: _______________________________________________
____________________________________________________________________________
Applicant Information
Name: (First, Middle, Last)________________________________________________________________
Telephone number: _________________________________
What was your relationship to person whose record is required? _______________________________
In what capacity are you acting? ___________________________________________________
If attorney, name and relationship of your client to deceased: ______________________________
Signature of Applicant: __________________________________________ Date: ___________
Address of Applicant: (Street, City, State, Zip Code) ______________________________________
____________________________________________________________________________
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BELOW FOR REGISTRAR'S USE ONLY (Photocopy ID and attach to application form)
TYPE OF ID:
_____ Driver's License State: _____ Number: __________________________________
_____ Other ID, specify: _________________________ Number: ________________________
TYPES OF ACCEPTABLE IDENTIFICATION
Do Not Issue Copy Unless One of the Below Types of
Identification is Presented
1. Driver's License
2. Non-driver's license
3. Passport
4. Naturalization Papers
5. Military ID
6. Employer's Photo ID
7. Two utility bills, showing applicant's name and address
8. Police report of lost or stolen ID