72 Hour Explanation Form
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher 1. Colsey
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY ]2590
WWW.TOWNOFWAPPINGER.US
(845) 297-4]58 - Main
(845) 297-577] - Direct
(845) 298-]478 - Fax
TOWN BOARD
William H. Beale
Vincent Bettina
lsmay Czamiecki
Joseph P. Paoloni
REASONS WHY DEATH CERTIFICATE WAS NOT FILED WITHIN 72 HOUR
TIME LIMIT TO TOWN CLERK'S OFFICE
DA TE:
MEMO TO:
NEW YORK STATE DEPARTMENT OF HEALTH
MEMO FROM:
ADDRESS:
IN REFERENCE TO DEATH OF
DATE OF DEATH:
PLACE OF DEATH:
I did not submit this death certificate within the 72 hour time limit because:
- Death certificate was not signed by physician or medical examiner
_ Family or next of kin was unable to be located
- Funeral home neglected to me death limit within limit
- Due to weekend or holiday, death certificate was unable to be med within 72
hours to lack of Town Clerk's signature, who was not contacted by Funeral
Director
Other: