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NY WCB C-64: Proof of Death by Attending Physician

When a death benefit is claimed in a New York workers' compensation, volunteer firefighter or volunteer ambulance worker case, the physician last in attendance on the deceased completes the C-64 Proof of Death. It records the accident, the nature and extent of injury the physician found, the direct cause of death, whether the accident was a direct or indirect cause, any contributory causes, and whether a coroner's inquest was held.

Who completes it

The physician last in attendance completes and signs the whole form in writing; in hospital cases, a licensed physician on the attending staff to whom the case was assigned may sign. The physician states licensure in New York and gives the WCB rating code and authorization number.

Submitting and payment

How to submit it
File the signed original directly with the Chair of the Workers' Compensation Board at the Board's centralized mailing address, and a signed copy with the insurance carrier if known, or the employer.

Good to know

  • Answer all questions fully; the form strongly recommends typewriter or computer preparation and requires the attending physician's written signature.
  • Question 13 asks for the patient's own words about how the accident or injury occurred, and question 14 for the injury as found on examination and later exams.
  • For a volunteer firefighter or volunteer ambulance worker death, the employer shown is the city, town, village, district or ambulance company the claim is made against.
  • The physician also records how long they were the deceased's medical advisor, first and last visit dates, and any other physician during the last illness.

Get the official form

Download the current version from the source each time; forms change without notice.

Proof of Death (By Physician Last in Attendance on Deceased)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who signs the NY C-64 Proof of Death?

The physician last in attendance on the deceased. In hospital cases, it may be signed by a licensed physician who is a member of the hospital's attending staff and to whom treatment of the case was assigned. The form requires the physician's written signature and a statement of New York licensure.

Where is the C-64 filed?

The signed original goes directly to the Chair of the Workers' Compensation Board at the centralized mailing address printed on the form, and a signed copy goes to the insurance carrier, if known, or otherwise to the employer. The case numbers go at the top if known.

What cause-of-death questions does the C-64 ask?

Question 15 asks for the direct cause of death and whether, in the physician's opinion, the accident or injury described was a cause, directly or indirectly, of the death, then asks for any contributory causes. Question 16 asks whether a coroner's inquest was held and, if so, the coroner's name.