Paoloni/FultonNEW YORK STATE DEPARTMENT OF HEALTH Notification of Appointment of Registrar of Vital Statistics
Vital Records Registration Unit
IM'P'ORTANT: This notice and oath shall be executed in triplicate immediately after appointment of the registrar and deputy.. registrar
fils~original copy with the New Yoh State Department of Health, ~lital Records Registrafioh_ Uhit, P.O. Box 2602,
AldanX,~lY~122~0-2602, File one copy with your County Clerk and retain one copy for your records.
Current Appointee New Appointee
flf reaooointment, enter correction only)
COUNTY & DISTRICT NUMBER
REGISTRAR Name
Town ity/Village
Street Address
City and State
Zip Code
Telephone Number ( ) Ext
(include area code ~ ext.)
E-Mail Address
Reappointment ~ewAppointment
If New Appointment, is this: Election ~ Resignation ~ Other
Effective Date of Appointment
(give month and year)
Is Registrar also Ci ~1-owr i Clerk? Yes
Length of Term
(give number of years)
Date Term Expires
( ive month and ear
_ .r; _
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Sigrrature of Appointing Officer
Title of Appointing Q.tficer
DEPUTY Name ,.
REGISTRAR - _
Street Address
f
City, State and Zip Code
Telephone Number
(include area code & ext.)
No
i
Specify Locality:
REGISTRAR'S AFFIDAVIT
STATE OF NEW YORK I do solemnly swear (affirm) that I will support the Constitution of thG United Stat
COUNTY OF } SS: the Constitution of the State of New York, and that 1 will faithfully discharge the d
~ ~ the office of Registrar of Vital Statistics, according to the best of my abilities.
,d' /' ~ I am not engaged in the business of funeral directing, embalmin or un ertakinc
/' / i~% '' n g ~c
Signed: ~ 1 ~ ,~ ~~ 7~:~ ~ T r/1?~S (lI~ (Q -(~l)
,' g trar of Vita t tistics
SubsEri ed and sworn to 6~
(affi~d) before me this ~_ day of
STATE OF NEW YORK
COUNTY OF ,~ SS:
Home Address
(..t'CLI.kC
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(~Z`t~-.-~-~' ~ Ext.
FAX ( ) _~ r°-
v; ~ -:-,.
Salaried: ~ Yes ~ No~-~' '~
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i.
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2-I 3t 12a i'~
J ~,. ;_
` Telephone
,,-•~ _
Ext.
T
~~l~Gu,O,~ ,rv' Notary Public "//~'~il~./~~'- 'k/~ ~'~~/l~/
DEPUTY REGISTRAR'S AFFIDAVIT (~/
I do solemnly swear (affirm) that I will support the Cons i ution of the United StatE
the Constitution ofithe State of New York, and that I will faithfully discharge the d~
the office of Deputy Registrar of Vital Statistics, according to the best of my abilities.
I am not engaged in the businessyo~f funeral directing, embalming or undertaking.
~._. f i:, 1 / ~ f 1 111 ~ ~ ') ~ ~~ .. ,-. ~. r. ~
Signed: / ~ ~ ~~ i ~ , iyl 7 • :-~I
uty Registrar of Vital Statistics Home Address
Subscrib d and sworn to - ~--d„ ~ ^~
(affirmed) before me this <> .t •~ day of ,~~ % , G~~% (~ Notary Publi
DOH-1550 (5110} ,- ~' ' ~ J0~>=PH P PAOLONI
;~ ~` Notary Public, State of New York
~% No, 01PA6295254
r` Qualified in Dutchess County
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