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NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for Copy of Birth Record
First Middle Last
Date of Birth (-)I �J W 19 1 -.
Name 00Qo7,P- M ceq M M D D Y Y YY
Hospital (If not hospital, give street 8 numb (Village, Town or City) County
Place of
Birth
l,l7tpd�,ll hcce� -
First Middle Last Maiden Name First Middle Last
Father of Mother
MCs�'re� K��s-t;.ti Lynn role
Number of Copies RequestedEnter Birth No. Enter Local Registration
if Known No. if Known
❑ Passport ❑ Working Papers ❑ Welfare Assistance
❑ Social Security-Retirement ❑ Schaal Entrance ❑ Veteran's Benefits
Purpose for Which ❑ Social Security-SSI Driver's License ❑ Court Proceeding
Record is Required Retirement ❑ Entrance into Armed
(Check One) ❑ Marriage License Forces
❑ Employment
❑ Other (Specify)
NAME Kt�sh� j__1, kA,( t= �j If attorney, give name and relationship of your
client to person whose record is required
What is your relationship to person whose
record is required?
❑Self [Parent ❑Other, specify
Telephone No. (name of client) (relationship)
Social Security No. Y- 3 o
�
Signature of Applicant Date ` ' e
0 �711 i
.GGC� MM DD YY i ,
Address of Applic ry
g1�3l
city State Zip Code
DOH-296A (11/94 ) Page 1 of 2
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ID: 401 307 755 CLASS D
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NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for Copy of Birth Record
First Middle Last
Name Date of Birth
d M M D D Y Y Y Y
Place of Hospital (If not hospital, give street&number) (Village, Town or City) County
Birth WKePi jgC12S - Wit ltu-C-H 'Ss
First Middle Last Maiden Name First Middle Last
Father �ere� KV Wpter of Mother ki LLI P,� mgo�/
KALLIW&L
Number of Copies Requested Enter Birth No. Enter Local Registration
if Known No. if Known
❑ Passport ❑ Working Papers ❑ Welfare Assistance
❑ Social Security-Retirement ❑ School Entrance ❑ Veteran's Benefits
Purpose for Which ❑ Social Security-SSI ❑ Driver's License ❑ Court Proceeding
Record is Required
(Check One) ❑ Retirement EJ marriage License ❑ Entrance into Armed
❑
� Employment Forces
LJ Other (Specify) �STRrE ISWES — +(pN otLCRS �r7.1S111-f�+ E'
'y
NAME iKQ4RJan6 NOw'f�o-¢i If attorney, give name and relationship of"your
What is your relationship to person whos'AsTe client to person whose record is required
record is required? r�
�seff El Parent 2'O//ttrer, specify `WV-i*A<
Telephone No. (Lttk) �:11016Aa s (name of client) (relationship)
Social Security No.1961�1-LkL(JH 03h
Date ' r,
nature of Applicants b �B i-
1,,,, 61,
�ulL. MM DD YY * _ C
Q
A� dress of Applican `"
s
str9eS ( N F I�CIIIL s
{� y �
Ci Stets Z ode
DOH-296A (11/94) Page 1 of 2