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Office of the New York

State Comptroller

NYS Comptroller

Thomas P. DiNapoli

NYSLRS

New York State & Local Retirement System

News Blog

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NYSLRS Report a Death Form

Use this form to report the death of a NYSLRS member or retiree. This information will be sent over a secure connection.

* Indicates a required field

Your Information

First Name: *

Last Name: *

Phone Number: *

Email: *

Address: *

City: *

State: *

Zip: *

Report a Death

Deceased Person’s Information

Please provide any known information for the deceased person.

First Name: *

Last Name: *

Address:

City:

State:

Zip:

Date of Birth:

NYSLRS ID:

If you don’t know the NYSLRS ID, enter the registration number or retirement number, or you can enter the last four digits of the deceased person’s Social Security Number (if known) in the next field.

Last Four Digits of SSN:

Date of Death: *

Place of Death: *

Other Information

Your relationship to the deceased: *

Employer:

Will you be providing a death certificate: * Yes No

NYSLRS will need an original death certificate or certified copy before we can pay any death benefits.

NYSLRS will need an original death certificate or certified copy before we can pay any death benefits (all original documents will be returned). Mail the death certificate (we suggest certified mail — return receipt requested) to:

NYSLRS

110 State St

Albany, NY 12244-0001

You can attach a copy of the death certificate to this email form now so that we can begin identifying any benefits that may be payable.

File Attachment:

Note: This form only accepts PDF, JPG, PNG and GIF file types. Maximum file size is 5 MB.

Was the deceased still working for their NYSLRS employer, off the payroll (but not yet retired) or retired? * Still Working Off Payroll Retired Unknown

Was the death as a result of an on the job accident: * Yes No Unknown

Are you the spouse or nearest living relative of the deceased? * Yes No

Additional Contact Information

If the deceased has a surviving spouse or other close living relative, please provide their contact information.

First Name:

Last Name:

Phone Number:

Email:

Address:

City:

State:

Zip:

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