TOWN OF NISKAYUNA
APPLICATION FOR BIRTH CERTIFICATE
For those persons born in the Town of Niskayuna.
Hospital birth records on file are from Bellevue Hospital after March, 1942.
Date___________________________________
Certificate Holder's Full Given Name at Birth:
_________________________________________________________________
Date of Birth _____________________________________________________
Full Name of Father _______________________________________________
Full Maiden Name of Mother________________________________________
Purpose for which certificate is required (circle one):
Passport/Travel
Kindergarten Entrance - One Free
Employment
Social Security
Social Services
Other ______________________________________________________________
Your relationship to birth certificate holder: ____________________________
*Birth Certificates are only available to certificate holder, their mother, or father
Your Signature ___________________________________________________
Mailing Address __________________________________________________________
**If Mailing Address is a PO Box, we REQUIRE a Street Address**
Street Address (if different)
__________________________________________________________________________
Fee: $10.00 cash or money order only (no personal checks)
If applying by mail, please enclose a copy of your driver's license and a self addressed, stamped envelope and send to:
Helen Kopke, Town Clerk, One Niskayuna Circle, Niskayuna, NY 12309. (518) 386-4511
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