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Niska Day Website
 
TOWN OF NISKAYUNA
Office of the Town Clerk
Bureau of Vital Records

REQUEST FOR A DEATH CERTIFICATE


Please Print:

NAME OF DECEASED __________________________________________________


DATE OF DEATH ______________________________________________________


PLACE OF DEATH _____________________________________________________
                                        Hospital or Street Address


Number of copies requesting   __________________

Certificate is needed for:

        _____ Insurance                 _____ Social Security
        _____ Bank Accounts       _____ Medical Purposes
        _____ Real Estate               _____ Other: _________________


Relationship to Deceased _____________________________________________


IF ATTORNEY:  Name and relationship of your client to deceased

____________________________________________________________________



        
        Signature       _______________________________
        
        Address         _______________________________

               _______________________________
        
        Date                _______________________________         



Send application with copy of Driver’s License as proof of identification and
fee of $10.00 (money order only - no personal checks) payable to:
Helen Kopke, Town Clerk,  One Niskayuna Circle, Niskayuna, NY  12309


 
One Niskayuna Circle, Niskayuna, NY 12309
Phone: (518) 386-4500 Fax: (518) 386-4592 | Hours: M-F 9 a.m. to 5 p.m.