New York Affidavit to Request a Certified Copy of a Death Certificate (Dual Citizenship) (DOH-5001)
Official state formOther copy requestsForm DOH-5001Free downloadLast verified November 10, 2026
Notarized affidavit used with dual citizenship requests to ask the New York State Department of Health for a certified copy of a relative's death certificate. The form itself does not print a fee or a mailing address.
Who can use this form
- A person related to the deceased who needs the record to obtain citizenship with another country.
- The death must have occurred in a city, town or village in New York State.
- The applicant signs under penalty of perjury before a notary public.
What to send with it
- The completed affidavit, signed and notarized.
- Photocopies of the citizenship requirements.
- Photocopies of any birth or marriage records needed to document your relationship to the deceased.
- On the affidavit, the name and relationship of each descendant from the deceased to yourself, and the name of the country.
Where to send it
- Mail to
- See the form for where to file it.
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- 5/10
- Source
- Official government page