Application for Copy of Birth Certificate

General Instructions:

• Do not use this application to submit your request by fax.
• Use this application only if you are the person named on the birth certificate or that person’s parents.
• We only process certificates in our office if an individual was born at Medina Hospital. 
• Do not use this application for genealogy requests.
• Print a copy of this application, complete and sign.
• Submit application along with a money order and a copy of the required documentation (see below).
• Include money order for $10 for each copy requested payable to the Clerk. Do not send cash.

Note: Payment submitted from foreign countries must be made by an international money order. Do not send cash. Identification Requirements: Application must be submitted with copies of either A or B: Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.

A. One (1) of the following forms of valid photo-ID:

• Driver license
• Non-driver license
• Passport
• Other government issued photo-ID

B. Two (2) of the following showing the applicant’s name and address:

• Utility bill or telephone bill.
• Letter from a government agency dated within the last six (6) months.

If no record is on file, a No Record Certification is issued and the fee is not refunded. Completed requests will be returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request. You can print out a blank copy of the form and then type or print the required information. Be sure to sign the form before mailing and include a money order with copies of the required identification. Return form and required ID to: VILLAGE OF MEDINA REGISTRAR 119 PARK AVENUE MEDINA, NY 14103 Include a money order for $10.00 to cover the cost of the certificate. Checks will NOT be accepted. MONEY ORDER ONLY.

Download Application

General Instructions:

• Do not use this application for fax requests.
• Use this application if you are the spouse, parent or child of the deceased.
• If you are not the spouse, parent or child of the deceased, then you must submit with this application a copy of documentation establishing a lawful right or claim (see below).
• Use this application only if the death occurred in New York State outside of New York City. Do not use this application if the death occurred in any of the five (5) boroughs of New York City.
• Do not use this application for genealogy requests.
• Print a copy of this application, complete and sign.

Submit Application with money order for $10 for each copy and a copy of any required documentation (see below):

• Include money order payable to the Clerk for $10 per copy.
• Do not send cash.

Note: Payment submitted from foreign countries must be made by an international money order. Do not send cash.

What is a lawful right or claim?

• If the applicant is not the spouse, parent or child of the decedent, a lawful right or claim must be documented.
• An example of a lawful right or claim would be a death record needed by the applicant to claim a benefit.
• Documentation would consist of a copy of a court order or an official letter verifying that a copy of the requested death record is required from the applicant in order to process a claim.

Identification Requirements — Application must be submitted with copies of either A or B:

A. One (1) of the following forms of valid photo-ID:

• Driver license
• Non-Driver Photo-ID Card
• Passport
• Other government issued photo-ID

B. Two (2) of the following showing the applicant’s name and address:

• Utility or telephone bills
• Letter from a government agency dated within the last six months

If no record is on file, a No Record Certification is issued and the fee is not refunded.

• Completed requests will be returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request.
• You can print out a blank copy of the form and then type or print the required information.
• Be sure to sign the form before mailing and include a money order.

Return form and required ID to: VILLAGE OF MEDINA REGISTRAR 119 PARK AVENUE MEDINA, NY 14103 Include a money order for $10.00 to cover the cost of the certificate. Checks will NOT be accepted. MONEY ORDER ONLY