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
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