Forms & Applications | Village of Medina

If you are in need of a birth certificate, death certificate or genealogy search please expand the title below for information on how to obtain your documentation.

The following forms and/or applications are available below. For further information, you may contact the Village Clerk’s office at
585-798-0710 ext. 2

Birth Certificate

APPLICATION FOR BIRTH CERT_0001

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 Memorial 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.

Death Certificate

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

Genealogy

Download Application

General Instructions

Use this application only for genealogy requests.
Print a copy of this application, complete and sign.
Submit application with a money order and a copy of any required documentation (see below) to Clerk.
If no record is on file, a No Record Report will be issued and the fee is not refunded.

For long search:

Available Records

No information shall be released from a record unless the person to whom the record relates is known to the applicant to be deceased.
No information shall be released unless the record has been on file for a minimum required period:
Birth records must have been on file for at least 75 years, death records for 50 years, marriage records for 50 years (both parties to the marriage must be deceased).
The time periods above are waived if the applicant is a descendant and provides documentation of direct line descent.
A party acting on behalf of a descendant shall further provide documentation that the descendant authorized the party to make such application.

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, along with copies of any required documentation.

Backflow Prevention Device Application & Requirements

Mail Five (5) Complete set of plans to:
Village of Medina – DPW
119 Park Avenue
Medina, NY 14013

Application for Backflow Prevention Device

Requirements:
Submission and Approval of Plans

In accordance with Section 10 of the Cross Connection Control manual, the submission of plans and specifications for the installation of backflow prevention assemblies must include the following:

A site plan (to scale or with dimensions) of the facility containing a general location map, name and address of facility, property lines, buildings, the size and location of public water main(s) and all fire and domestic water services, meter pits, yard piping and hydrants, pumper connection(s), interconnections, and the location of the proposed backflow preventer(s).
A plumbing floor plan (plan view) or partial floor plan indicating water services, name and address of facility, water meter layout, proposed backflow preventer(s), booster pump system, floor drain(s) and all nearby objects (examples: electrical panels, boilers, chillers, storage tanks, fire pumps, fire sprinkler risers, etc.). The plan must be drawn to scale or with dimensions indicated from walls and all nearby objects.
A vertical cross section(s) of the proposed installation with elevations from floor, ceiling, outside grade and all nearby objects.
All drawings must include the name and address of the facility, be stamped and signed by the designer and have a clear space for approval stamps.
Engineer’s Report
An engineering report must be included with the plan submittal. The report must describe the project in detail. Items that should be included or described in the report include:

General use of water within the facility;
Size and description of all fire and domestic water services;
Number of floors within the facility
Actual or estimated maximum flow demand;
Pressures – existing and after the installation of the backflow preventer;
Description of the fire fighting system – indicate the A.W.W.A. Manual M-14 class of sprinkler service;
Description of the proposed installation of the backflow preventer – indicate the location of backflow preventer, drainage, lighting, heating, access to unit, square footage of the floor level where the backflow preventer is to be located;
Description of the existing or proposed booster pump system, answering the following questions:
After the installation of the proposed backflow preventer(s), will the Net Positive Suction Head (NPSH) required for the proper operation of the booster pump system be adequate?
After the installation of the backflow preventer(s) in the suction line to the booster pump system, will the booster pump system operate properly at peak demand to deliver adequate pressure to the highest elevation and/or most remote fixture unit or any other operation requiring a certain pressure? Note: The New York State Uniform Fire Prevention and Building Code Part 902.4c requires the minimum pressure at water outlets at all times to be as follows:

Fixture – non flush valve – 8 psi
Fixture – flush valve – 15 psi

Does the booster pump system have a pressure cutoff switch in the suction line? What is the pressure setting of the switch? An existing or proposed cutoff switch must be set at the following setting?

For a cutoff switch where the backflow preventer is located upstream of the booster pump(s) – set at 10 psi.

For a cutoff switch where the backflow preventer is located downstream of the booster pump(s) – set at 20 psi.

The need for dual backflow preventers. Does the facility need a continuous water supply?
The elevation and location of the 100 year flood plain in relation to the facility. A reduced pressure zone (RPZ) backflow preventer must generally be installed 1 foot above the 100 year flood plain elevation.
An inventory of any existing containment devices to include the make, model, size and serial number of the device. Current annual test reports must also be submitted. The degree of hazard for these services must be determined to insure that the device provides the correct protection.
Certified Testing and Completed Works Approval

After an approval of plans has been issued and the assembly has been installed, it must be tested by a certified tester. The designer (or water supplier) is then responsible to certify that the installation was done in accordance with approved plans; or describe any changes or submit “As Built” plans as appropriate.

The initial test results and certification are then submitted to the water supplier and approving agent for issuance of a Completed Works Approval. DOH – Form 1013 has been designed for both the certified test results and the designer’s certification of the installation.

After issuance of the Completed Works Approval, the assembly must be tested at least annually by a certified tester with the results reported to the water supplier.