2014NEW YORK STATE DEPARTMENT OF HEALTH General Information and Application
Vital Records Section, Genealogy Unit
P.O. Box 2602
Albany, New York 12220-2602 For Genealogical Services
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
1. FEE - =22.00 indudes search and uncertified copy or notification of rro record.
2. Original records of birthsand marriages for the entire state begin rvifft 1881, deaths begin with 1880, EXCEPT for records filed in
Albany, Buffalo and Yonkers prior to 1914. Applit~tions br these cities should be made daectly to the local office.
3. The New York State Department of Health does not have New York City records except for births occurring in Queens and
Richmond counties for the years 1881 through 1897.
4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical
research.
To insure a complete search, provide as much information as possible.
Please complete for type of record requested, berth. death OR marriana
Name at Birth ~r"~6~~,~ 1~~~(J 1
Date of Birth ~ ~~ ~ 5~ ~ ~ ~~ 3
Place of Birth W~~rnIf~14(.~P,/1~5 ~d (~S
ii G'Y1 r`~ r `e Y~ ~ 3~~ 3
Father's Name -~1 ~ c
Mothers Maiden Name~~1CQ/J ~(.~ Z~
Name at Birth 2olor _ l/t~
Date of Birth ~~ ~ ~ 3 ~ ~ ~ ~ ~
Place of Birth ~~~~~ '1~ ~ '
C Vl l~~ L-`Y~ '~c~~~~
Fathers Name
Mothers Maiden Name ~ 5 t`I ~
~~':w~~` Name of Bride Name of Bride
X '
::~
..., Name of Groom Name of Groom
`
~ Date of Marriage Date of Marriage
:. ~
~ Place of Marriage Place of Marriage
<~
~
...y and/or License and/or license
'~`
,,;
Name at Death
Name at Death
Date of Death
Age at Death
Date of Death
Age at Death
Place of Death
Names of Parents
Name of Spouse
For what purpose is information required? ~
What is your relationship to person whose record is
In what capacity are you acting?
SIGNATURE OF APPLICANT
ADDRESS
l~
DATE ~ ~ ~ ~~
c "L
Send record to; (please pent) If reques ing birth and marriage records, please sign the following
,~ ~ ~~ f statement:
Name ~ ~ Ci?~ To the best of my knowledge, the person(s) named in the application
Address~I `1 ~ ~~ ~ l0 1 L
Ci J V 7 State~_ Zip Code ~ dC7~-C.~ TURF Ot= A ~ ~ceNT ~~
DOH-1562 (06/2003) (over)
NEW YORK STATE DEPARTMENT OF HEALTH General Information and Application
Vital Records Section, Genealogy Unit
P.O. Box 2602
Albany, NewYorlc 12220-2602 For Genealogical Services
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
1. FEE - =22.00 indudes search and uncertified Dopy or notification of no record.
2.Original records of births and marriages for the entire state begs with 1881, deaths begin wfih 1880, EXCEPT for records filed in
Albany, Buffalo and Yonkers prior to 1914. Applications for these cities should be made d~edly to the local office.
3. The New York State Department of Nealth does not have New York City records except for births occurring in Queens and
Richmond counties for the years 1881 through 1897.
4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical
research.
I o Insure a complete search, provide as much information as possible.
Please complete for type of record requested, birth. death OR marrianc?
'~`
~~ Name at Birth -~~b~~~ ~~~ • •
Name at Birth
' ~ ~
~
•~•>• Date of Birth -
~ ~ Date of Birth
1
:. • ~ Place of Birth 1 S ~ ~~ ~~ Place of Birth
" c
::><:>;
`'~'`~ Fathers Name Fathers Name
~~
~
'
..,.., Mothers Maiden Name
~~
~ (~
~_ ~ • Mother's Maiden Name
Name of Bride
Name of Groom
Date of Mar-iage-
Place of Marriage
and/or license -
Name at Death_
Date of Death _
Place of Death .
Names of Parents
Name of Spouse_
Names of Parents
Name of Spouse
DATE
For what purpose is information required'? G 9iYl7.c~ ~ act ~1
What is your relationship to person whose record is requested? l~l,ffil?
In what capacity are you
SIGNATURE OF
ADDRESS _ ~l ~ -~ t°cl 5
Send record to: (please print)
Name ~Uc~'~~j'(u~li~(~ VV1,C~'V~
Address `-t~ ~ ~c~~ ~~ ~~ l
City. ,(~ ~Z~ ,-~ State_~ Zip Code
Name of Bride
Name of Groom
Date of Maniage-
Place of Marriage
and~or License -
Name at Death
Age at Death Date of Death
Place of Death
Age at Death
i~/~
c- ~U~~~s~..
If requesting birth and marriage records, please sign the following
statement:
To the,kest of my knowl~ge, the person(s) named in the application
are seg. ~ l
DOH-t 562 (06/2003) (over)