Approval of Appointment of Subregistrar of Vital Statistics
NEW YORK STATE DEPARTMENT OF HEALTH Approval of Appointment of Subregistrar of Vital Statistics
Vital Records Section
SEND TO: Peter M. Carucci, Director, Vital Records I
P.O. Box 2602, Albany, NY 12220-2602 District No.
To the State Commissioner of Health, Albany, New York
Under the authority of the provisions of Section 4122 of the Public Health Law, I do hereby appoint, subject to your
approval
as Subregistrar of Vital Statistics.
The location of registration services will be
(Area Code) Phone
street Post Offlce
or at such other place as shall be deemed necessary.
Zip
This appointment is necessary for the convenience of the people in this district for the following reasons;
Print (or) Type Registrar's Name
Approved by
Signed
Date
Registrar of Vital Statistics
New York State Commissioner of HeaUh
Date
STATE OF NEW YORK
By:
Peter M. Carucci
Director
Vital Records Section
) ss.:
County of
I do solemnly swear (affirm) that I will support the Constitution of the United States, and the Constitution of the State of
New York, and that I will faithfully discharge the duties of the office of Subregistrar of Vital Statistics, according to the
best of my ability.
I am not engaged in the business of funeral directing, embalming, or undertaking.
Signed
Subregistrar of Ydal Statistics
Home Address
(Area Code) - Phone
Subscribed and sworn to (affirmed) before me this
day of
Notary Public
DOH.2457 (4/2000)