Birth Certificate Application - 202010221421507684

Application to Town Clerk
for Copy of Birth Certificate

Donna Lent, Town Clerk TC-01 rev. 06/20
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738 (631)
451-9101 FAX: 451-9264
BIRTH CERTIFICATES
The Brookhaven Town Clerk’s Office maintains birth records for individuals born in the Town of Brookhaven, including
births that occurred in Port Jefferson through December 31, 1963, and in the Villages of Lake Grove and Mastic Beach to
the present. Any births that occurred in the Village of Port Jefferson from January 1, 1964 through the present are on file
with the Village Clerk of Port Jefferson (631) 473-4724.
The only individuals eligible to obtain a birth certificate include:
 The person named on the certificate.

 A parent of the person named on the birth certificate is always entitled to a child’s birth certificate
(requesting parent’s name must be on birth certificate).
 A person who has court-ordered legal custody/guardianship of the minor child listed on the birth
certificate. If the applicant has legal custody/guardianship, a certified copy of the court order must
accompany the request.
 An individual who has notarized authorization from the person named on the certificate (if 18 years of
age or older) or either parent listed on the record. If the applicant has notarized authorization to obtain the
record on behalf of an eligible individual, the original notarized statement must accompany the request.
Identification Requirements: Applications must be submitted with copies of either A OR B*:

A. One (1) of the following forms of valid photo ID:
 Driver’s License
 DMV issued Non-Driver Photo ID
 Passport
 US Military ID
 Naturalization Papers
 Permanent Resident Card
 Employee photo ID plus a pay stub from current employer
 Police report of lost/stolen ID
B. Two (2) of the following showing applicant’s name and address:
 Utility or telephone bills dated within the last six (6) months
 Letter from a government agency dated within the last (6) months
 Pay stubs dated within the last six (6) months
*If the applicant’s name on the ID differs from the information on the birth certificate, a copy of the applicant’s
marriage certificate, legal name change paperwork, citizenship papers or naturalization papers must accompany
the request.
ANY REQUESTS FOR A BIRTH CERTIFICATE TO BE MAILED TO A POST OFFICE BOX OR TO A THIRD
PARTY MUST BE NOTARIZED.
Fee: $10.00 per certified copy requested. No more than two (2) copies will be issued within a twelve-month period.
Payment may be made by check or money order payable to “Donna Lent, Brookhaven Town Clerk”.
TC-01 Page 1of 2

Application to Town Clerk
for Copy of Birth Certificate
Donna Lent, Town Clerk TC-01 rev. 06/20
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Applicants should mail the completed application to the Brookhaven Town Clerk (see attached instructions for additional
information or visit www.brookhavenny.gov). Required ID and fee must be included with application. No more than two (2)
copies of a Birth Certificate will be issued within a 12-month period. Make check or money order payable to Donna Lent,
Brookhaven Town Clerk. Fee: $10 per copy or No Record Certification. Please do not send cash or stamps.
CERTIFICATE INFORMATION
1. Name (as listed on Birth Certificate):
First Middle Last

2. Date of Birth 3. Place of Birth: Hospital (if not hospital, give street and number)
4. Village, Town or City 5. County

M M D D Y Y Y Y
6. Father/Parent’s Birth Name: 8. Birth Certificate No.: (if known)
9. Local Registration No.: (if known)

First Middle Last
7. Mother/Parent’s Birth Name:
10. No. of Copies 11. Amount Enclosed:
Requested:
First Middle Last
12. Purpose for which Record is Required: (Check One)
Passport Employment Driver’s License Veteran’s Benefit
Social Security Working Papers Marriage License Court Proceeding
Retirement School Entrance Welfare Assistance Entrance into Armed Forces
Other, Please Specify: ____________________________________
APPLICANT INFORMATION
13. Name: 14. Telephone:
( )
First Middle Last
15. What is your relationship to the person 16. If attorney, give name and relationship of your client to person whose record is
whose record is required?: (If self, state “SELF”) required:
Name of Client Relationship

17. Address of Applicant: 18. Name and Address Where Record Should Be Sent: (If delivery is to a
P.O. Box or third party, you must submit with this application a notarized
statement signed by the applicant stating such.)
19. Signature of Applicant: 20. Date:
This office requires written authorization of the person/parents whose record is requested.
TYPES OF ACCEPTABLE IDENTIFICATION: FOR REGISTRAR USE ONLY
1. Valid Driver’s License DO NOT ISSUE COPY UNLESS ONE OF TYPES OF ID IS
2. Valid State-Issued Non-Driver’s License PRESENTED. Photocopy of ID and attach to application form.
3. Passport Type of ID:
4. Naturalization Papers Driver’s License: State No.
5. Military ID
6. Employer’s Photo ID with Pay Stub Other ID, specify:
7. Two Utility Bills Showing Applicant’s Name and Address
8. Police Report of Lost or Stolen ID No.:
TC-01 Page 2of 2

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Application to Town Clerk

for Copy of Birth Certificate

The only individuals eligible to obtain a birth certificate include:

 The person named on the certificate.

Identification Requirements: Applications must be submitted with copies of either A OR B*:

TC-01 Page 1of 2

First Middle Last

4. Village, Town or City 5. County

6. Father/Parent’s Birth Name: 8. Birth Certificate No.: (if known)

9. Local Registration No.: (if known)

Name of Client Relationship

19. Signature of Applicant: 20. Date:

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