New York Application for Copy of Pregnancy Loss Record (DOH-3667)
Official state formStillbirth and pregnancy lossForm DOH-3667Free downloadLast verified November 10, 2026
Notarized application the patient uses to request a copy of a pregnancy loss record from the New York State Department of Health. It is mailed with a copy of identification to the Bureau of Vital Records in Albany. There is no fee for the certificate.
Who can use this form
- The patient named on the pregnancy loss record.
- The applicant swears or affirms that they are the patient and signs in front of a notary public.
What to send with it
- The completed form, signed and notarized.
- A copy of your identification.
- The name and address where the record should be sent.
Where to send it
- Mail to
- New York State Department of Health Bureau of Vital Records P.O. Box 2602 Albany, NY 12220-2602
- State fee
- There is no fee for the certificate.
- Typical processing
- Not provided
- Form revision
- 04/26
- Source
- Official government page