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2010 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coer of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PRINT OR TYPE Name of Deceased Date of Death or Period to be Covered by Search Elaine S. Gray December 25th, 2010 First Middle Last Name of Father of Deceased SocIal Security Number of Deceased Frank Walsh 113264361 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Helen Genshur Jan 19 1934 76 First Middle Last Month Day Year Place of Death '3~ Wappinger Dutchess Name of Hospital or Street Address VillaQe, Town or City County Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? Funeral Director ..__m__.....___ If attorney, name and relationship of your client to deceased ---_._~_.- Signature of Applicant -~ Q Date I -Z-j:zSl lio -----.--- I Address of Applicant - - COMPurreFORDEATHSOCCURRINC AS OF JANUARY 1 1988 ~----- Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death PLEASEPRINTNAl,tE.ANDADORESS WHEAERECORDSHOULD .SeSENT Name McHoul Funeral Home, Inc. Address P.O. Box A City Hopewell Jct. __ State NY Zip Code 12533 DOH-294A (6/2000) c? NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Name of Deceased GV(1US+ J. First Middle Name of Father of Deceased A U(JU-Sf-vs First Middle Last Maiden Name of Mother of Deceased ere, c-e.. A-. S~ 10. J ,,~ 0 First Middle Last Place of Death 5" 0 Cose...e ~~ Name of Hos ital or Street Address Purpose for Which Record is Required 0- da,rY\S Last PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search December 24, 2010 A-Jo,fr'S Social Security Number of Deceased 117-- t.{ )- .... 0.:( / 7 Date of Birth of Deceased C>~ D~ /"'S3 Month Da Year Age at Death s"7- Dutchess Count The family requests this record for purposes pertaining to insurance and property settlement of the deceased What was yOur relationship to the deceased? In what capacity are you acting? h.nero.l If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant Date December 28, 2010 ~ c:>r'\lt1'/(~. f-t'Y ,~+-'- 3 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 ~ Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death ~~~~~~~[Q) ....,... Cl n 'In'i''\ UCl. ~ v L.V'V PLEASE PRINT NAME AND ADDRESS WHERE RECORD ,n. .Ppl .1 ... Name I ...., ';-O\~I'J_ .~LERK Address City State Zip Code DOH-294A (6/2000) i' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased F1\<t..~.J{\CK \)(.tV I 0 First Middle Name of Father of Deceased :: .:'" ':, . JR" Il'ffr,: :af1lMlSIfttt'tl:\):tl}:(:):itit:}:)til):tt)):fi:lt:i)::tIt! Date of Death or Period to be Covered by Search Ro~~~, SR. 01/01 /J 0 Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last ;? () ~ - A 1- J 04 \ Iq3~ Year W~()P)JJ6-cz.R ~ Villa e, Town or Ci Date of Birth of Deceased If) \I Month Da First Middle Place of Death Last Name of Has ital or Street Address Purpose for Which Record is Required OU1C H~SS Coun I Gr1k R\>OSiS I N lbN~U:110U W17H- -rH'~DWz:U/ s <t:..s-r; 'fl?_ What was your relationship to the deceased? ffi10RN~'-{ fOR Oe-uGkt'1l2.-R.... eJF.. Otc~ ,of' v-t,I:JA-NJ6 In what capacity are you acting? ~ 8& PrL CfW ~c I ..., '1 If attorney, name and relationship of your client to deceased (!,h.1 ~ N I \ S DPs UGH 1 ~ r<- ()~ Dy~<c 0'2}.lJ Signature of Applicant ~ Date_' A ,- I G,-I 0 Address of Applicant ~.5 ~r..~f.j fl \) ~ A\J<2l\.llll( J CA-R H Y_L... ~ Lf I 051 2..- I R\~ - Number of copies requested with confidential cause of death . ~ Number of copies requested without confidential cause of death ,. ... .... .,.. ::t):,tf:(@@}!:ttPLEA ,E:PRIHlliNAM, :iAN.. :/,,: ': :', , Name -Jjt.LJ '1'^-J ~\R M O~ \A. \ I LL.J 1\ M Address b~) ~"~N€-\ ~~ PN~tJlA€. City C ~R H l(, L- State --1l:1 Zip Code J D51 2- DOH-294A (6/2000) ... <<fl SAYEGH LAw William G. Sayegh Andrew W. Humphreys Robert A. Weis Joseph S. Sayegh Giuseppina R. Lita Kenneth S. Rones Debora J. Dillon Nicole K. Trivlis Nairn Bajraktari, Of Counsel THE LAW FIRM OF WILLIAM G. SAYEGH, P.e. The Sayegh Building 65 Gleneida Avenue Carmel, New York 10512 845'228'4200 sayeghlaw.com Dutchess County 1 100 Route 9 Fishkill, New York 12524 S. Barrett Hickman, In Memorium retired Justice of the Supreme Court of the State of New York December 16,2010 Regina Shaw Ali, Executive Administrator Town of Wappinger 20 Middlebush Road Wappingers Falls, New York 12590 Re: Frederick David Romig, Sr., Deceased Date of Death: 04/07/2010 Social Security Number: 202-24-1041 Dear Sir or Madam: This office represents the Janice Rickard, who is the daughter of the above name decedent. We are writing to obtain one (1) Certified Certificate of Death for Frederick David Romig, Sr. In connection therewith, I have enclosed an attorney's check in the amount of $10.00, representing a fee of$1O.00 per certificate, the Application to Local Registrar, as well as a postage prepaid return envelope for your convenience in forwarding the Certificate to us. If you have any questions regarding the above, please do not hesitate to contact me. Thank you for your attention to the foregoing. Very truly yours, .,.-.-~--;..-~::::.~ ~ -~ ~._' j~/ --~..-,..." ~/,-'r~ ~ '..'.A" f-P '/"~"./' Nicole K. Trivlis, Esq. The Law Firm of William G. Sayegh, P.C. Encs. I\H~W YCml( STATI:. DEFJAI~TfVII::J'\jT OF HI::::ALTII Vllal l=il"cmcl.s SI:lciiol! --. - - -~l~'" J....~.......,.....I__,_......I.....HIol.t__...~tl._1LOOl Appncation to LOGal Registrar for CoPy of Death Record r --~----,- --''LE'/IS'' COiVIPLF'fE FOI"M AN D ENCLOS E FEE -~~E. '~, 0 DO ~:'~:"V DI '"0 ,"oeo',' C" "'lCa"ol!. Plea'" do 1101 selld ca,h or stamp' --.....-..-_-- ,':,".;. ...:"::' .. _.------...--.,.---~.;_._-_.._-. ..:.>~:_:_-____________~___ . ........ '.. .... .PLEAHE:PR'lNTORTYPE ... /\lamc-) erf Deceased -----.---------.-- Date of Death 01 Perlocl1o be Covered by Search Gu 5oT4'1'0.A. IV R..o l=-ir~3t Middle I_fist -----.----.--- I\Jam e of I=- dllll'!I. 0'1 Deceased NO t. ;);). -:lCdO Social Security '\lumber of Deceased U tv i< fl) . 0 7 () _ S-o ~ _'1 &:2. / Flrsl Middle I_flst .--------------~~~-_. -. lVIaiden l\Jame Df Mother 01 DC-!Geasecl Dale of Bllth of Deceased U IV i,( ^' . .J ffrJ S; Firsl___ Micldll0 Last Month Day FJlace crl D(0Clt11 ------------. ELf111/7 4T WI-/P/'/NGEI2S FnLl....$ CAh~I'/,lttlc:c"'7~ ~/lt..L5 J~i:lfne of Hospital 01 Stlflet Acldre~,s Villc1ue, T~II UI Cily l::JurposE'lol' Which Ilecorel is Il(~CIlJirG)c;---------' I q itS- Year Age at Death " ~- Pu/ofes5 County -----_..I..~!ff....?..TLf 1C5..!f/tTc.- _.______._. VVlkll Wi.IS youllelallollslllP to lilt' cll?CI::'ClSC-!d? _EJ 1~-?..4Ld2../.../!.Cc.70.e.... In what capacity are you acting? _____..~51::) IY c:____. If attmlwy, flall'le anclleIClliol)~Jhlp ur your client to CI[)CeClSl~cl (;inrliJtwe cd ApplicElIll___ d~_tl-=---~.M.~ Dale /2... Ill- -rO AdcJress of Applicclllt... Gi-f E, M.t!.!.tY'.__~_y"',__...k!J..Ii~tk;;FP~_~(..5_ ,v/~ /2Stla -~---_._--._----~-~-~~~-~---.._--~~--~ ------------.-----.----. ..... ':.......'. ,..... .....:,:.:. ,.:";;", ......... COMPt.:.~n~_FQ.B.DEj.~IJ::!.~OCJ~URflINGAS OF JANUARYl,l988...... ..' ._:J_ NUlllhE)r 01 copies leqLle~-;tE!cI with colTriclr:~lltiElI Ci:1USG' of cleath 1\ILllnlx~r of copil:\s Il=>CjLI?slpc! without cDlTficlerrlinl caw,p of cleat! ~\~J~~~~~jQ) '- .. ..~~~--~~-.~--JjI:EASEJ:\RTi~fr.Nj.\ME ).1.N1:)~A'DDF1ESSWH EFrEFl .' ----'-.~-----.----;v--------- -' . . , I\JEllTle .--__.2J;~ 1/'Y,Ct;.*'II4.4Nr ---- ._-._----_.----._----~. Adclles~:; ---- -~..-.---....-_~_._--~-~-----_....._-------,-_. -------~~-------- -~- ---------- --- ------~- City _________._..___________________ Stale Zip Code --~...._------~---._-~.__..._---------_.._~_.._~_. Weu.LJn @ .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record . 'M"'MD'" ....ENCL... .: '::: :,,:: .:. ::;.... :';'. .,' ,',:.', ,':', ..... ... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~dle Name of Father of Deceased . :::: :.::..'..: :t.'.: Date of Death or Period to be Covered by Search WI tlstf ef' ,.. - Q..~ - 0 ? Social Security Number of Deceased First Middle Pla;q otDettd rY\ ~ b. I Name of Has ital or Street Address Purpose for Which Record is Required Last oftoo f '> ) '- 0 s-'-~ I 3 6 Date of Birth of Deceased 'i l' Month Da Year (. wa PO 1 VV). e...r- ~ Age at Death 10 /);"k)1e>> Coun First Middle Last Maiden Name of Mother of Deceased What was your relationship to the deceased? So (\ In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant LLt~ , Date /;;7-/9-/lJ ~ Number of copies requested with confid~ntial cause of death - Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) ~ 4-~. PW7HCTC3Oll "0 .. . dO 0 q - d;).- NEW YORK STATE DEPARTMENT OF HEALTH Vilal Records Section Application to Local Registrar for COe)' of Death Record ...... ...../PtE;A$~ coM PLETE ..F()HMANOE:NctO$eFEE"/ , ...:'.' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name 01 Deceased G1 Flr~7J3 c, 1?obe~ Last Date of Death or Period to be Covered by Search 12.-\-\0 Middle Name 01 Falller of Deceased ,^,d\\ o.rn 1-\ "Rdbe<~ First Middle Last Maiden Name of Mother of Deceased . J qe~,,",e.~ ~-hQ....l First Middle Last Social Security Number of Deceased 5 c '--\ - <0 '-\ - '2-~~Ca Date of Birth of Deceased 5-\\- 5L\ Month Da Year Age at Death -Sk Place 01 Death SIc> NC1'-\o~ 1<.<1:; ~ Name of Has ital or ~et Address Purpose for Which Record is Required M\-=t- '~~~s County ~ ci~ Gk What was your relationship to the deceased? ~h.P_rt70--\ \::\(~C'--\?-,;--, In what capacity are you acting? C>V\ b ~ l-P a -Q -C-VV\ \'lu... If attorney, name an~hiP of your client to deceased .-J . . _ _ SIgnature of Applicant ~ Date \2- C 'D Address of Applicant t=b ~_ l~\, \f\..\~~~ ~\~S, t':J"f 1231.0 . .........,,'....-....._.... . -...-......COMPLETEFOR DEATHSO'CCURRINGASOF'JA (@Number of copies requested with confidential cause of death "';';':':':':',':'7".:;::'.:'. .....'........ ..................... ......... ....-.'.,. ,',-." ..................::::;.::pLeAsEPRINT'NAMe:ANtiAtiDRe.S$WHERe.R.: D ~CC~~~~\Q) ___ Number of copies requested without confidential cause of death Name__ . Address _ City ______ State Zip Code I\I""\LJ i)r\ 'I ^ Ie l'if$\f'\\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Last Date of Death or Period to be Covered by Search ;1/11/ID Nam~.9fDeceased y--e \Jt f"\ First Middle Name of Father of Deceased tos :> Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last Date of Birth of Deceased Age at Death First Place of Death Middle Last Jp.. ~~~O'v Month Da Year Name of Hos ital or Street Address Purpose for Which Record is Required UEU ().~ <;L~t~_ roL c.~ What was your relationship to the deceased? ~O~ In what capacity are you acting? I\. \ Y) P ~V( rL1t:> k),,- If attorney, name and r7s i of your client to deceased Signature of Applicant l t-.J J Address of Applicant " f( 'S'" v~ )4 ; c; A- vlJ'.. Date / 2--/ 0 ~ / jl-) I I JJ$'-) ,2 jPj C' Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death State 1J'f Zip Code /zS'9D DOH-294A (6/2000) I\J[::VV ycml( 2~lAIT_ DEF'AI=1TIV1i::I\JT CW Hi::::ALTI'1 VllC11 1=j(ClClll'cL", ~;I='C:lIDI) - ,- 1_._~Ir__1 .._----~_.&- Appncation to Local Registrar for CoPy of Death Record [------ ____._ ---------I;)LE./.\SE C01V1Pl~-E:TE FOIWI AND ENCLOSE FEE '--~~~~--;I~IO OC~~:)V UI /\Jo ReCOI(I-~dIIIIICaIIClII F'ledSl-c' do nol senel cash 01' stamps, PLEA SFP HINTOn:. TYPE ~_._-,._----------~~ Date of Death or Pmiod to be Covered by Search l\lalll(-l of DrCiU!ElSUcI (J&TeR. 1=llc,t W. Middle N A J.I LEAl tic..;. ;l~, .:tolO I_as! Sowed Secullty l\lumber 01 Deceasecl I\JdlTle 01 F'lliwr 01 D(-lceased GoDFRey NflH/..€AI _~ilsl Mldclle ____._I_clc~_____ Ivlc:licll011 1\),111)(0 or lV1utl'lC-:JI' (], Dec:ea:3ecl II III tII fI FilS! 0&'/- ~,- 63/'7 Date 01 Birth 01 Decea~,ed Age at Death Middle C!..o57EL/..O La,',t '1 Month :13 DClY 193;.2.. Year 'Tff F)lacI~ 01 [lpath .5"tt Ro8~1<., LRrJJr J~arne olllospltal or Slltle Aclclree.,': --------~------------_._--_.. l:lUI-POSI' Ill! WI-ICII I~\ec()lclls Il(~qLIIIl,~cl W A I' ,01 N (" -eJe ~, TOWll or~ ..D()~i-/e>S County TD se T1L.~ /ES74TE Wlldl Wil~; your !cdalicJIlsliip to Illl' clecl'i.:lsecl'! ___,..E(/!')Lt?R~- .J); IZEC-TOt:-, III whL'l1 Ci:1I1ilClly all:' you i:lClII1C)/ SA 114';: L ..._~______._~____..___.___" Ii at\ollwy, l1iJlm' (lIIclrl0lElliol1ship of YULlr cllc~r)1 to clGCI~aSlc!d :;~~:':::';,;'~::::::',',~';lt ~;_~'!!:!::;;/>1v G-€ ~E"l; s 0:; 'f II;", ~ ~; 0 ___~_ cmm:..hs:n:FoB DE~IJ::I~.9CClJRBING AS OF JANUARY 1,1,988 (, f\lullllll?r 01 copies requestecl wil:h cunllclclllllctl caw;e 01 death [R1~~~~~~[Q) 1\lulnliiO:'1 of c()pic:~s II)qLle~-;lllcJ WilJl0Lll COITflclerltJi,t1 caLise 01 deer -1 NOV;' 2 4 2010 TOWN OF WAPPIN REC ------~~------ _____.___E'.LE~~:rJRTi~fL!~A-ME A-lli:;-A'tJC HESS. WHEFlI -l(~~----- , ) l~cllrIE: ..._----.._--------------_._------------------_._~....--.-------.----.---.......--. Adcllesc:; .._~-----..-._-~.-._--~_._-~~.._~._.-~.~--_._--_.~._---~-----_._-- Cily __m_m____.__~____.______m__~____.___.u___ ;jtate Zip Code ~1."""__~'''''''I___'''.''IIl.~_iolll_''"'''' AppUcation to LOGal R'egistrar for CoPy of Death Record I\H~\IV YOI={I( STATI:. DEF'AFnlVIENT 01= I-II:::ALTI'I Vllc,II=jI"COI'cl" E';I:,ctJon - -- -'~~'''''' L ----- - ----I;)LE/\Sj~~CC51ljjPIJ=:fE FOF11VI AND ENCLOSE FEE __- I~~E~:.IO.U() 1""~'OI'Y~ R8:~.1 C8 ~'I"'at'o'" Please do not send cash 01 stamps " . ,,,.. ..... '. ... . ", . -_._.._._-._-----------:.....~_.._~..... P LEASE.:PRINrOHTYPE ~Dale of Death or l:Jerioclto be Covered by Search I\JWT1L'J of Deceased G- UST4\1c fl. Toao _~r~ot ______._____M Icldle ___________._J!I_~..______ No v: ::l ~. .;;)0 I t!> [\Iame of Fallll'JI. O'r Deceased 1=llsI UNKnJ. tvI iclcl 1(:. Social ~3ecurity l\Jumber of Deceased 6 '7d - 56 - 3 g Z I I_clst .JRN Month ;, Day / C;/.fS YeElr Age at Death , ~""- IVIElIclen l\Jame of Mother 01 D(~cei:l:)ecl UtJI<N. r::II~~____~~ldl~_____Jl2:~L.._.___ I:JlaceoID{~Clth ELAN, Itr wAPfJ. j::'LS. Date Df Birth of Deceased W4Pf3IIl1Gct25 FALLS JUrc.HE S',S County J~arne 01 1-lospit31_~~. Slle~l Adc:lrec,~:; ___________ ViIlClD8, T~or~ I:JLllpOSG'lol. \lVhlch HecOlcl is 1l(~qLlil'!O'C1 7~ S.~LE tST/iTF --~----~~...-~----.__.._._---~.~.,---_.. Whdt wm; yourrelallullship to 1llE' c1l~CE'l:1S8c1? _.__.r..c;,!.1I.eR.Rc.. J),IZ€e-T(J Il...- III what cl'lpacrly are you actlllg? --____~-_.J:j-~_'!'..~ II altOlTl!OlY, l1ame ancllelal:iordllp of yuur client to clcH.:easm1 ~;I~lflalllle of ApplicalTt __~__#,~~~ Date 1/- ~d-IO Adclress or Appli~;21llt Ie~ e L12lil._!Y..__..sL__..wA.eeL1'!6.s-R5_PI'9US, fl,y_ /2s.-.ya -------------.~----~-~--~-~._--_..__._-~~ --~._.-._- ", . .,,':.".:.'. ,.",'. .. '''0' .._ .....;.. ....., .... -_______ . COMPLETE FOR DEJ\TI-!:jOCCURRINGAS OFJANUARY:I,1<98S..... ---........-----~_..----_.-.:.-.:....:..--_.__._---_. ..:1.,_ Nurnher o[ C:(lpll~S reCjLlesllxl wil:h CUlTliclr:!l'ltial Ci:lLlse or cleath 1\lwnbel' of cupies 18qLi?stml without confide Till cause of death DBESENT<.:.. . -.........-.---.....~._.-----~-~----~-~.._---~---_.-._.- - _-.-:-;----=-~-==----"...15'LE..itsEJ1RTi~fr.Nt\ME )~N'[)~/\ DRT:ss~S: ----....--.-----;v---------- ---- . I\jCllTJe _..___________.._______.______.._______ _IQWN OF WAPPING Adclress TOWN CLERK -- City _____________.______________________ State Zip Code ---..,.~-------.-_._---.__.,._-------~,.-~-.-~_.-. I\Jl::W ycml( STATI:: DEF'I,\I=iTI\lli::I\JT OF" HI::ALTH Vilal l=il"cCllcI" ~-;l:!c:tJOn .... - Appncation to Locai Registrar for CcpV of Death Recor~ _~'_'" _1._,-~~l---'lIIii...""".aIII-"''''''-'.'''' ,..:": .... ~----_.--. __._._____________.__~_____~!:'L:EAH[:.:P-F{INTOJ1TYPE l\]a\1w of Deceased Date of Death or F'eriocl to be Covered by Search Gu5Ttlvo A. ToR.o NO v- d:i. ::JOIO F=irsl _____._.~iddl(? I_Elst 1\lame of l=alllI'Jr. 01 Deceased ----.----.---..--.------- Social Security l\lumber of Deceased U NlbJt>w III l=ir~11 Middle U:tst ---~---------_._-_. lVIaiclen l\Jam8 of Mother 01 Deceased UN ~ N't/w I\J FW31__._~idd\e Last r~-'Iace 01 D{~ath E LltrJ-;- A-1-W~f1~lIvc;..-iR.5 - O?b', 50 - 3S;l. / Date of Birth 0'1 Deceased -1A 1\1 .5", I <; If ~ Month Day Year Age at Death ~ !:l- W/-JPP1II14€!?J ;:::,qU...5 -Pure-HeSS County J~arne of I-lospital_~~ Slrl'\et Acldrec;s Villaue, T~1l 91' Cit~' --~~---~--_._------_.- l:Julposl:'lor Whlell Hecordls 1l(~quirl':'c1 --~------~-._----_._-----_.-..-----~-_..~------- 10 S e-rrlJ2 e S"\ A- T e: VWldl Wi\S youll'eli.:lIIOIlSII!P to lilt' c\ecei.:\sC:lcl? ____.E.v.j).t6t<~(..- ))/ REGTO f2-. In whal CiJpElClty all? you actllliJ? ______~~---~-1~_e- If altollll:'Y, 11i:lITle ctr1c1lelatioldlIP of your client to c1Gc:easl~c1 ~)i~lflalllle uf ApplicElllt _~--.d...~....AA~ Date Adclress 01 Appli;:211l1 ._~.,g...JJ4.llL.tJi__s.r;-...wIl..e..e./Jv&E&-E/lLLS /I) If 1/ - ~3-IO r2..~q6 -_._-~."_..~-~~--~~~----_.---~ _~__~~~ cOMPuin~-FOR DEJ\Ti~.soCCURRINGASOFJA----- --.. -..---.'--' -.- .. --..... ---------.------- -. _ \\ f7 ~ 0 .__~__ NUllll)[~I' 01 copies leCJue~-;lecl wil:h c:cmliclolll:ial C,;lu~;e erl cleath ~~~~~ ~ 1\lulTlber of copies IIX\U?stElcl Without cOlTficlenlli..\1 cause 01 clei: th NOV' 2 3 ?O'iG __ -...-..-.-:--~=~.=~---~--Jf[TE~?E-!:lRTi~fr.NI-\ME ).\Ni~A'DD'Fn:~;SWHERE: -. -----;v---------- . ~..-..--..........~._---------_......_.....---.-------_.-_.~~ -----~- l\l ClITI e _________._______.______ _________.____________.___ Adclles~3 -----~-~._----_._~.-.--------_._-_._--------- City ___ Stale Zip Code _ - -----_._~---~------_.-------~- ~-----------_._-_._.._----~--------_.__._. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Name of Deceased Julia First Middle Name of Father of Deceased Hugh First Middle Maiden Name of Mother of Deceased Ellen First Middle Place of Death Elant At Wappingers Name of Hos ital or Street Address Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement of the deceased PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search Howard November 22,2010 Last Howard Last Social Security Number of Deceased 040-32-8740 Ahearn Last Date of Birth of Deceased 3 28 Month Da 1938 Year Age at Death 72 Wappingers Falls Villa e, Town or Cit Dutchess Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relations .p Signature of Applicant. Address of Applicant 1028 Main Street, Fishkill, NY 12524 --Date November 23, 2010 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 10 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Address City DOH-294A (6/2000) 35l~~ TO\I\}N Of WAPP TOWN CLERK Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Col!)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased / 5rEJJfllfl1./' First Middle Name of Father of Deceased LIJ U Ij First Middle Maiden Name of Mother of Deceased If-i:>e!e . to 4c?0 First Middle Last Place of D~~ --f-.: ' :: (,. I CJfJ cJ 11+(1( ~'O~ Name of Hos ital or Street Address Purpose for Which Record is Required ROss Last ~V Last Date of Death or Period to be Covered by Search I r !f<(Iz-C/ro Social Security Number of Deceased Ilf - 3 0 -- /3:::S- Date of Birth of Deceased /~ f1-lr 7 It( yo Month 0 Year ..J.) AP/J ~pL Villa e, Town or Ci Age at Death 7(/ 't:urdrR: 5'5 Coon What was your relationship to the deceased? r ~J D l O!--z--(~ h-- In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~~ Address of Applicant I (f/ .. ~ - tf",; f:.~ ~ I rJ 8- Date A c{V~.Q/~ 9 ~ {Jar r'l.-t (() Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for COe>' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Robert James Fiorella First Middle Last Name of Father of Deceased Pasquale James Fiorella First Middle Last Maiden Name of Mother of Deceased Amelia Valentine Maccarot First Middle Las Place of Death (".. Date of Death or Period to be Covered by Search April 25, 1996 Social Security Number of Deceased Date of Birth of Deceased April 30, 1957 Month Da Year Age at Death 38 Name of Hos ital or Street Address Purpose for Which Record is Required Villa e, Town or Ci Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased Father Signature of Applicant Address of Applicant 59-40 Date /I /3 J/O / I ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death NOV 0 8 ZOJ TOWN Name Pasquale J. Fiorella Address 59-40 Queens Blvd., Apt. 17E City Woodside State NY Zip Code 11377 DOH-294A (6/2000) ,~o ~uJW ,iund Howard L. Fiorella 60-10 47th Avenue Woodside, New York 11377 917-975-7979 November 5,2010 BY OVERNIGHT MAIL Town of Wappinger 20 Middlebush Road Wappingers Falls, NY 12590 Attention: Sue Re: Death Record Dear Sue: I enclose an Application to Local Registrar for Copy of Death Record signed by my father (also father of the deceased), a copy of his driver's license, and a check for the fee of$10. As per our conversation earlier in the week, I would also appreciate any information on where he is buried since that is ultimate the purpose of this search, to pay our respect. Thank you so much for your assistance in this matter. J/ere1y, () . Jr& ~ella encls. .; " ~; ~r> ~~ Comn'l'S",,-,rOfMolor ~rnc~Dl~JVER LICENSE 10:275 600 768 OOB:os-a.eo :o:e~Nt':v WOoD ..i' NY 11m SEx:.. EyE"$;.... MT: IJ.Ot CLASS 0 E lit: & ISsUED.~~ -.,......" 7..(~ 3Olf603:Jo t NEW YORK STATE DEPARTMENT OF HEAI.TH Vital Records Section Application to Local Registrar for COe)' of Death Record ".PL.EASE OMPLETE.F RMANOENCLOSEFE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ,', ';"",', Pc ."p.' ":::'.'.,: ': 1.':." .'.,:. ..... '. ..:PLe;AsE.PRINT,OATYPE'...."... :.... . ...,.. . ,.', P .' . '. '. ' ...... Name of Deceased Date of Death or Period to be Covered by Search ~(\ eX'\L C WO-\~e..(" I 0 )11 I ~ ()() <0 First Middle Last Name of Father of Deceased W\ \ S6n Social Security Number of Deceased · L.e '{ 6'1 First Middle Last Maiden Name of Mother of Deceased uJ IIS6V7 Date 01 Birth of Deceased ",2- Age at Death A'lce.. 10 .;21 q2 First Middle Last Month Day Year Place of Death . '-', -€.... Ffftl S 'DLLklAes s :fib 6fd~t/? If S5 161-. i)JOL.P pi Ilt:f e rs Name 0 Hospital or tree Adi:lress Villaae, Town or City Countv Purpose for Which Record is, Required I 13e V1~ ~-k What was your relationship to the deceased? clG.UD. \y\ \e.- r " In what capacity are you acting? If attorney, name and relationship of your client to deceased Signo'ure of Applicant ~ .Q..lLlL} ~ 0... J~ /1 )};Q , , Address of Applicant jJ Cc> ~t!. < 7ft.j c. h e s.kr } "-t-;( o "'os ~ Number of copres requested with confidential cause of death - Number of copies requested without confidential cause of death .. :PI,;EASEPRINT'NAME:ANDADDR $WHEAflECORDSH Ut.DSESEN Name Address City State Zip Code DOH.294A (6/2000) , , I~~ ~ ,I' "WALKER . J ......~~...., '.::~l~'~ D08: ~,!~~; see: F EYEs: 'iR}'lti''l.tO E' NONE ~'"".; 4 R': NONE'" i1';'''., 1 1SSUElJ: ~10 EXPIRES. 04-03-14 AKCK211AF11 J ....'. ", " . f'pJr l eJ\ e \- fl,c)-O 1: L..(jOL \ l~ r /0 II I/:J-{JV (<; ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record PLEASl;CONlPLETEFORMANO ENCLOSE FEE . T6Yu1 S. First Middle Name of Father of Deceased (f c5\Lrl S- First Middle Maiden Name of Mother of Deceased ~\..~ yY\~~~ First Middle Last 0 Place of Death ~:t ~ QA>~ Name of Has ital or Street Address Purpose for Which Record is Requir~d €U-~~ . .........PLeASEPRINTOR TYPE> Date of Death or Period to h-\-~valol ~ast \O-~~o-o\ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased h~~ Last Social Security Number of D o'SV;> - ~'-\ - c:Y1.~ Date of Birth of Deceased oe.- oy - \ q4 ~ Month Da Year Age at Death '-03 or City ~~ss County Signature of Applicant Address of Applicant What was your relati~nship to the deceased? ~ olA r:e-~ In what capacity are you acting? ~ ~ ~~ If attorney, name and relationship of your client to deceaseclJ - , 1 1<) & llalvey ...:.tr \l Ii J \. .1t(1 <11 .::7 ( .. "'treet -. ,;:, hlc,\ :-. \(l~n ~J . . I,.ils "y 125 \\',lpplll~i.('fS '( ..' . . \0 .. ,..............,... ....COMPLETE FOR DEATHSOCCURRINGASQFJANUARY14988<............ .. ~ Number of copies requested with confidential cause of death tP Number of copies requested without confidential cause of death .... . ..............pl;eASEPRINtNAMeANOAOORe$$\NI-fERl:Rl$CORt>sHOuJ..,()EU;Sl$NT>.... Name Address City State Zip Code ~ DOH-294A (6/2000) .I.______~_.&- Appncation to Local Registrar for Copy of Death Record I'JEII: ycml( C:TAn: DEF'ARTlvlENr ore HEALTH Vlli'll HIC>CUI'CJ.c, SI',c:lloll - ,_. l_'_~,__,-" r---------------- -__ _____~__ PLE/.\SECOl'V1F'LETE FOIWI AND ENCLOSE FEE ~~~~[~ 10. OC I'''' ""py~"~,, R "W d : H' 1 d 'La ,,,',,. PI 08", do n" 1 s end La, h 01 , tam ps PLEASLPR1NTDB,TYPE -_.._--~~-~-_.._---- Dale 01 Death 01 Pel-iod to be Covered by Search l'JalllC-: 01 HELENE I=ii,;l Mlcldll? ------------~.---- I\JC1rnc:~ DI F'llI 1(';1 , 01 Deceased EGt3ERT I_Ci::il o C. ~9/ ~O) 0 Social SecLlllty Number of DeceElsed FRt!l>€t? ,ex:. HER"J&.-cG- hr:; I M Iclclle I_ost ~---------- ~~-_.._-------_. MClICII':'1l l\JamB erl Mother oi Deceasecl /40 - /8 - 9-3(;3 /1117121 ELI:EII/ Fil:ol 1V1Ic1dlt? ._------~---- J/Ev/ /\IE L,21:::;t Date or Buth or Deceased PEe. a 3_ /9~o Month Day Year Age at Death 9'9 F' bee; 01 Death 3/ T/fEl(c$-1 /S/.,li{J4 J~drne oll-iLlsplt.<::!_~~ Slll'le!:.. Aclc~~~::::__________ I~)UIP()S(' IUI Which HecOId is IlI'!CJuIIIC\cl 7D "5c77L€ 8'5.7/77(( Wit f?,0I1/GeIC. V~, Towll 0ILli:.\L- .,l) uTt:. HESS. Coullty -~~--_._-._.._--_._-~~..~---.._---_., WIICII Wi1~; Voullc!iallullslllP to IIIl:! c1ecel:lst;c1'! ___JJ.Jk~~ .})/ i2IFCTtJl!:..- III what Cclpi1Clly alE' you L1C:tlll~J?_______SRf'!i.._~~___ 11 attolllG'Y, fliJlliE' 2l1idlelEl1iollShip (,I YIlLlI cliellllu cIHc:(,ast~cJ C;ionalllll! 01 Applici'lIll _n__~_.a:_A_~ Date /0 - ;2,d11-( () Alklres,: 01 API~li(:fllll n-k!t:.-~~/.':t.'i-Ld_:::LL_____1&!.I9LL/fIG-c;?S 1dlGLS4 /V. Y / :!-!>-90 ~--~_._-_._'~._~------------------~~--------_.__.. _ COMP1:~:n~:FQBDE~IJj::;OC~:;lJRf1]NGAS OF JANUARY 1, 1988 -_LQ I\) II In 111:'1 01 cupic's 1l';CjLll?sIIXI with COITllclerltlcl! Ci1u,;e ur death ----- 1\lul11iJel or cupi(IS II?CjuI:?,;tml WiU1UUt cOllrlclelltlid CElUc,e 01 cleatll lRi~~~U~~[] ---------------PLEASEP R Lf~h- .r~AMEANl;~A-DCRESS.WH ERE RECORD -----'---------~-------y----~-_:.._-------'--- OCT: 2 8 2010 E -I. TOWN CLERK ~._------._.-----------------~--_.._----~----. l\j fllTI (! Ackll(';s~:; City -~---------___n_______________________ ;jlale Zip Code ---~~~-~---_._--~~---- -~-------- NEW ~RK STATE DEPARTMENT OF HEALTH Vital fcords Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. PLEASE PRINT OR TYPE Name of Deceased Date of Death or Period to be covered by Search Evelyn M Morgan October 23,2010 First Middle Last Name of Father of Deceased Social Security Number of Deceased Oscar Lindblom 076-36-8540 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Bertha Granbom 10 4 1943 67 First Middle Last Month Dav Year Place of Death , Wappingers Falls Wappinger Dutchess Name of Hospital or Street Address VillaQe, Town or City County Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement of the deceased What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and re'C:) of your client to de~eased Signature of Applicant Date October 25,2010 Address of Applicant 900 Rt. 82, Hopewell Jet., NY 12533 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE EC Name Address City tf DOH-294A (6/2000) .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased EILEEN M. MASTERSON First Middle Name of Father of Deceased WILLIAM BENNETI' First Middle Maiden Name of Mother of Deceased CAroLINE GANNON First Middle Place of Death 60 S. MESTER AVENUE Name of Hos ital or Street Address Purpose for Which Record is Required ESTATE ASSETS Last :.:' .INT)"... Date of Death or Period to be Covered by Search JUNE 25, 2008 Social Security Number of Deceased 118-09-4256 Last Last Date of Birth of Deceased JUNE 25, 1920 Month Da Year Age at Death 88 WAPPINGERS FALIS NEW YORK Villa e, Town or Ci DU'ICHESS Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationshi l\'JTT'QRNE;Y FOR EST.?\.TE ATTORNEY Signature of Applicant Address of Applicant Date to ~ - Number of copies requested with confidential cause of death . ~ Number of copies requested without confidential cause of death Name Address City 92 EAST MAIN STREET WAPPINGERS FALLS State NEW YORK Zip Code 12590 DOH-294A (6/2000) ... JOHN L. SUPPLE GREGORY D. SUPPLE* PAUL B. SUPPLE *NY & CA BAR JAMES J. LYONS (\919-2008) LYONS & SUPPLE COUNSELORS AT LAW 92 EAST MAIN STREET P.O. BOX 46 W APPINGERS FALLS. NY 12590-0046 (845) 297-0600 FAX (845) 297-8877 E-MAIL: SUPPLELAW@AOL.COM BEACON OFFICE 5 CLIFF ST.. P.O. BOX 227 BEACON. NY 12508-0227 (845) 831-1234 October 1, 2010 Town Clerk Town of Wappinger 20 Middlebush Road Wappingers Falls, NY 12590 [R1~~~~~~[Q) OCT 0 42010 TOWN OF WAPPINGER TOWN CLERK Re: Estate of Eileen M. Masterson Dear Town Clerk: I am the attorney handling the estate of John S. Masterson. Please forward five (5) copies of his wife Eileen M. Masterson's death certificate, who passed away on June 25,2010 in the Village of Wappinger. We are enclosing herewith our check in the amount of $50.00, along with a self- addressed envelope for return of same. If you have any questions, please do not hesitate to contact this office. Very truly yours, /" NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrc. for COe.>' of Death Recor~ . ..... ........PLeASgCOMPL.ETEFORMANOENCLoseFEE. ........ ...... . ....: . .. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ... ......... ... .1 ......;......................................../ . .... Name of Deceased Date of Death or Period to be Covered by Search Firs tj.Je/e,J !;,I)v It > 10/cl9/...2BJ() Middle Last Name of Father of Deceased Social Security Number of Deceased Ev ')Tr ~~o> )0 ur fI- 3 I /~ '- ~6- V~ s-:;C First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~,,/tO '/J<1/rl~ )~Je ~ ' 07 .z7 I'll? /3 First Middle Last Month Day Year Place of Death , I M 1/,> t 1;~7 &T ?4J-//-- ~.5e') ~41/S V~~// -v )~n J) tJ/C 4f'.J. j Name of Hospital or Street Address (CIIIIage) Town or City County Purpose for Which Record is Required C 5 i/!-r e What was your relationship to the deceased? FV/Ve"p' 'Il- / tfJ;"ret 70' In what capacity are you acting? SO~ If attorney, name and relationship of your client to deceased Signature of Applicant ~~~ Date /6/..L V/U , Address of Applicant ) Cl y,-/ gf'(J u C/ev ~ y .---v 7 --y /cJc!1 Y ... .. ....... COMPl.ETE FOR DEATHsbcCURFm~GASOFJANUARy.1;198ti<:;;;.. ...... L( Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death ... .......p.UtASE"F>fUN"tNAMeAN[.)AODRES$WHERERSCOR[.)$HOOL.OElE$EN!':. .. Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not s N~f Deceased J..J()()CIU., k. .s~~t First Middle f.as Name of Father of Dec~d COX\ l-toch-<-\J\ First Middle ~'\.ast Ma~:~t:; ~other of Dece~~J()')a. S First I Middle Last Social Security Number of Deceased O-,q - 3 Co - " 194 Year Age at Death (J; l../ ~\.NtJ\L~ Coon p~se4ogo~tMk 9 Apt LJ( Name of Hos ital or Street Address Purpose for Which Record is Required ~ Si+tl9. What was your relationship to the deceased? u..r\.U""Q...\ ~ \. \" ~ " In what capacity are you acting? 'h.uu.xo...-\ \::) \c.e.Go\c, If attorney, name and relationship of your client to deceased If2:-I : J I L 1 A'1A- Signature of Applicant / ~~ I ~ Address of Applicant @L[ W ' ~ o~ .3 ~ I ~co n f a v+. G, 6>0/0 ,D~!Ef I "-J '{ / JS" 0 ~ t- - Number of copies requested with confidential cause of death . _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) I\lE::W YORI< STATE DEPARTMENT OF HEALTH Vilal Recmci" Sl'lction Application to Local Registrar for Co of Death Record j:JLEASE COlV1PLETEFOHM AND ENGLOSEFEE FEE: $10.00 per copy or 1\10 Recol-d Certification. Please do not send cash or stamps. l\Jame of Deceased EDDA Fil-st Middle l\Jame of Father of Deceased EWALD Filst Middle Maiden t\JamB of Mother of Deceased A fl/IV /V7 4 t<IIE- Firsl Middle Place of Death ELANI 41 WflPP. ;;L-~. Nam e of Hospital or Street Address PUI-posefor Which Ilecord is Required PLEASEPR1NTDRTYPE Date of Death or Period to be Covered by Search E LL~R. Last OCT. (j,. ~o i 0 Social Security Number of Deceased J-)aMUTH' Last 07']- :3if- 7/?1-( L EEsc.fI Last Date of Birth ot Deceased II ~ 9 Month Day .LIt Year Age at Deatll ~% WfJP~/N(;'-€'I?S F,-~. VillaGle, :fawn gr City J:> VTGHesS County TO >€7TL€ Es;. T ~'I::.- What was your relationship to the deceased? ----.EUrYt:7c At.. J) (r?G'L-7 0 "- III what capacity are you acting? __ Sri "" e- If attorney, nallle ancllelatiorlship of your client to deceased Signature of Applicant - ~.A~ a. A), .fJ-~ AddressofAppli~ant_ ~'t- L. iJ?"f'v 5T... wl'1~~//tJ~71<;' P/9-LL5 Date III;~ /0 - t. - 10 , Z,S;<1o COMPLETE: FOR DEATHS OCCURRING AS OF JANUARYll988 ~ Numbel- 01 copies I-equested with confidential cause of death Numbel of copies requestE!d witllout confidential cause of death PLEASEPR INTNAME AND ADDRESS WH ERE. HECORD<SHOULD BE SENT. .. ....... ...... .r , , Name __ Address City State Zip Code ~ ....~ ,-., t , ,.., '"" .,.. 'r, !.-. r-. ...... ~. \ . Application to Local Registrar for Coe.y of Death Record .. NEW YORK STATE DEPARTMENT OF HEALTH .Vital Records Section .'Pl.JaA$IQQUPlJeTI$,OA...NQJ;NQl.,Q$gPE15 " FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased 7A -<. ~.-1) c),"Q...... C. First Middle Name of Father of Deceased J/l-fOVA/~ Last Date of Death or Period to be Covered by Search /o/A.sP tJ C. Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last Ocfr ?' 7' of?, Date of Birth of Deceased / /' /..3 / l.-''1...- Monfu - /' Da Year Age at Death P"; First Middle Place of Death W."97t('\ ~<UIj ~j Name of fios ital o( Street Address Purpose for Which Record is Required Last JU~j ,- Coun What was your relationship to the deceased? S 0 .."\J In what capacity are you acting? S c) J"\../ If attorney, name and relationship of your client to deceased ,. Signature of Applicant Address of Applicant ~2f- -- , ./ J' ~-...f I?i>( ~ O-'L Date (.'(/ -,1" I ~ ~ / 0 ,/ r:~Yl> / ~ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City ~.. ./ . ........ '.' .. .... NT' .,',. ,', .... ..,...,,,,,.., .. . .. ..... ..".-,,-,---. - ... '. -. ... . -,.".......... '." ... . '." P''''.'''.'' .,_.... . '.." " . .....,..............PI,.;eA.$ltPRJ..., .... .....NAM, o c"', V (J DOH-294A (6/2000) .. ~-----~"~"---------."--------~-- . ---- · ~STATE' .....-;".. " , ,-.y' '.' '.' .1 -. .~ . ~J "":.c~~ DRIVER. LICENSE 10. 231 l.~ 681 CLAsS 0 i -l'-. ~ ~?7--'- .. . . NEW YORK STATE DEPAR:rMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased MOJ\\1 D. First Middle Name of Father of Deceased N; CO\CJ.. First Middle Maiden Name of Mother of Deceased Con~ First .........'.'...}.':...pueAs.e..:aalN1?QR..mY:a....:~Jt:n.::f..:r%mm:..ll!tm:m:.~t.@itl..m..{{~~mtm'::.:.t?Jm::{.::;::=.p:".;........ . j) Date of Death or Period to be Covered by Search 1~(;if)O Qu. 7 aOIQ Last J ~-e. \/;"{o Last Social Security Number of Deceased 063-5'-/- ~q Middle Grcew Last Date of Birth of Deceased ~ 18 .Month Da 19~(j Year Age at Death 90 ~~ Place of Death ~ 60f' p/QCQ. Name of Hos ital or teet Address Purpose for Which Record is Required --TO ~*l!L Count What was your relationship to the deceased? V~\ ~'i\.p[J\O \ In what capacity are you acting? ~ vU'lQJU.,\ b if ..e.v-\c.:f If attorney, name and relationship of your client to deceased Signature of Applicant ?~ (J., JIn 1~ Date Od . Address of Applicant @lJ W; \low i"-h~d' ( ~ifJf) J KJV la6'()~ $? . aUIO , - Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death fR1~CG~a'Y~[Q) Name Address City ".,.:"..:,:>>:,.::;,...::",:..::: .. .... :...... P.......t.....l2.A....... .:...S....E........'.p....:aINt.NAMe::ANttAbi:Ui,i:es.:s:::waea:S? . ;.:. ::-::>:. :::: <:: <::::<:~: :;:::. ........... - '.' .'. - "." State Zip Code ~!l4A (6/2000) .' TO: Village ofWappingers From: The DiDonato Funeral Service, Inc. Date: October 19,2010 RE: 3 Death Certificates on Edda Eller Please mail the certified copies to: The DiDonato Funeral Home P.O. Box 537 Marlboro, NY 12542 Thank you, Keri DiDonato Votta lR1~~=J~~[)) OCT' '1 2C'~O TOWN Or WAPPINGER TOWN CLERK NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record . ...PLEASl;COMPLETEFORM ANOENCLoSEFEE<. .... .....< FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased \ ~a. \cd D C \J\ ~n::>\f\<=-~ First Middle U Last Name of Father of Deceased NoVY"\c.h I \0 C\Ji \o.v\OVI C l.---. First Middle <.J Last Maiden Name of Mother of Deceased La ~',:::> First Middle Place of Death f 2'T Be.e.c:h~ Crc-l.e.- Name of Has ital or Street Address Purpose for Which Record is Required r . t:::y~ of.- G k At~i ~ Date of Death or Period to be Covered by Search i-2"Z--\b Social Security Number of Deceased 06-=t - i5L\ - 2122 k~Yl~kl Last Month 5-~\- Da Ca~ Year Age at Death y+ Date of Birth of Deceased ~ \-c.-~S County What was your relationship to the deceased? _FiAII\e~L-hre...c~ In what capacity are you acting? CVl tr~~\...p- o'~ -tri..V"n';~ II attorney, name and 'LiP ~f you:;:. 10 deceased Signature of Applican Address of Applicant c.) . ..... COM PLETE FOR DEATHSOCCl.lRRINGA$OFJANlJARVd198S<<...................... . Number of copies requested with confidential cause of death . .............pl,;EASe...PRINI..NAME..A.NDAP Zip Code _ Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Col!)' of Death Record ...... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Hehrl First . Middle Name of Father of Deceased ) tJ5.r>,P" First Middle Maiden Name of Mother of Deceased '"'(olN/tl s 1<:- y Last I<v,v~'}/~ ~ y Last Social Security Number of Deceased Date of Birth of Deceased Age at Death First Middle Place of Death Last Month / / Da 2- Y uJltlf'Me'- F~//! Villa e, Town or Ci I~LY Year e~ o l.J k{~ .s.s Coun Name of Has ital or Street Address Purpose for Which Record is Required Doc v Mt7~J /P6-4-! (! / ~i~ What was your relationship to the deceased? AJ uve In what capacity are you acting? S'r'(' ~PlA-~1 I. fk....fK~4-d F.. r.e..i11e>~ i( Ifattomey, name~eceased Signature of Appliean ,:, ~. Address of Applicant 1 ~ Cl "N\~ -sS u ?-,,)l ~?- 8p~~v,-/"...) AntiC- DfJI.~ 2.~ (t ~ rleK!~€&J) ~"( 11 {"{"~ ~ Number of copies requested with confid~ntial cause of death ~ Number of copies requested without confidential cause of death Name Address City Pro'li~/~(....j-Il-6P""'-'1 2.72... ftlp~1} Dn.. /J I}f bul'lc~t. Zip Code IS- 2. "3 fj DOH-294A (6/2000) '* ~ D (2Ju1zd 4Wrd, L11 -0-1 \~ ~ Fro.rn: Bill Gentile At: Provident Agency Inc FaxID: Provident Agency Inc To: Pete OCchipinti Date: 9f.20f.2010 08:50 AM Page: 2 of 2 ."" - Main Office 272 Alpha Drive - PO 80x 11588 Pittsburgh, PA 15238-0588 TolI.Free: 800-447-0360 Phone: 412.963.1200 Fax: 412-963-0415 - - PROVIDENT Insuring America's Heroes Since 1928 September 20, 2010 Hempstead Fmns Benevolent Assn Attn: Pete Occhipinti Fax: 516-539-0116 Re: Hempstead Fmns Benevolent Assn Group Term Life Policy #: 129557-0201 Dear Pete: As you have requested, we have prepared this response regarding the group life policy above. Provident provides a group term life policy for members of the Hempstead Fmns Benevolent. In order for Provident to process any claims under the group life policy, a certified death certificate is required along with a notice of claim form and beneficiary designation. The information can be forwarded to: Provident Agency 272 Alpha Dr PO Box 11588 Pittsburgh, PA 15238 Adjustor: Bill Gentile Ph: 800-447-0360 Fax: 412-963-0148 Please feel free to contact our office should you have any questions. As always, we are here to be of service to you. Yours truly, William Gentile Representing Providen/' Life and Casualty Insvrance Company and affiliates of Chattanooga, TN .... Scott Clark 1st Vice-President Peter Occhipinti Corresp. Secretary Joseph Keegan Financial Secretary John Grillo Treasurer TRUSTEES Ralph S. Fraile Engine Co. 1 William Sielski Engine Co. 2 Richard Cain Engine Co. 3 James Sandas Engine Co. 4 John Grillo Engine Co. 5 VOLUNTEER and EXEMPT FIREMEN'S BENEVOLENT ASSOCIATION of HEMPSTEAD, NASSAU COUNTY, INC. Organized April 25, 1940 75 CLINTON STREET P.O. BOX 32, HEMPSTEAD, NEW YORK 11550 Kevin Candido President Richard Smith 2nd Vice-President 24 September 2010 Town Clerk Town of Wappinger 20 Middlebush Rd. Wappinger Falls, NY 12590 Re: Henry Kowalsky - Death Certif. Dear Sir, Enclosed please find form DOH-294A for request of Death Certificate for person listed above who was an insured member of our association. Also enclosed is letter from Provident Insurance (insurance carrier for our association) stating need for the request. Thank you for your time and consideration regarding this matter. Brian J. Smith Hose Co. 1 ~rs truly, Richard Szencze ki C\ -: ~... ' Hose Co. 2 :~ John Occhipinti Pete Occhipinti Hose Co. 3 Corresponding Secretary Carroll H. Kyser Truck Co. 1 Robert A. Noonan Truck Co. 2 G~r-~ GEORGE F. FOSTER Notary Public, State of New York No. 01 F06138728 Qualified in Suffolk County . / 'I. Commission Expires December 27, 20(..L NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record .,....-........... . ................ . . . . . . . . . . . . . . . . . . ......, .. ................'...,.......................,...... ..........,....... ...... ................. . . . . . . . . . . . . . . . . . . . . . . . . .. . .............................", . ............................................,'. ............ :,:".W,:P. :LEASEL ':'" . ..... .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased iM1X~ J3ttRON RC:1I1tJNC2.Y First Middle Last r Name of Father of Deceased iMRE ~R. EIt~ON KO/.fONCZy First Middle Last Maiden Name of Mother of Deceased .. I' . .':' .':' .. ... '::::.::. ".:;::::', Date of Death or Period to be Covered by Search Social Security Number of Deceased Date of Birth of Deceased Age at Death First Middle Place of Death (I tV H J 6 rl ofll! /.:::. J ql /VIY ERS. coR.5, R. D, Name of Has ital or Street Address Purpose for Which Record is Required _ To 5 &t t/ \,V Pi( 0 f;l'F TO l--l 'J=- I;: Last Month Da Year WjAPPI N<;~R.s FLS. hUTCHESS Villa e, Town or Ci Coun , INSuRANCJ;- COMPANY What was your relationship to the deceased? W ( D CJ \,{j In what capacity are you acting? to R.. M Y S ~}. F If attorney, name and relationship of your client to deceased . . J.-tHtCi :BMl1J 'KHUk~ Signature of Applicant Address of Applicant q I /11 Y f3 /? 5 Co {(S. 7< D, ( UtI f9 P 1}.J G ~ f.<, s f\( oN S Date q /;.,:2. / :2 0 / 0 , . F'/l/-l$ , NY, , ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name ~ Ie 0 t< ~ t' ft" b II r ~ A~dress q 0 rv! 7' ..ere, c (s (2,{J City l.)n ffj .P{'s F&l /' S i. L.: f t t' /'l t € ( ~ r: q 1(5 State ~ I ~ \j - ( Zip Code I J. Cj 1 () DOH-294A (6/2000) cfn / / ~ d } - 800 ex, ""iE" ......... ,1LONA,e\ \:' ..cpS CORNERS "*; , '",.. ' ERS,LS ~,,1., ~f ; .09-11-23 ,',.. . J '$SC F EYES: SA HT: 5-03 f: N0t4E ..... . RHONE '. . .... ...".., ""''' "'''.''..:-- . .. 6~ STATE DEPARTMENT OF HEALTH ....,.r.1'Records Section ~ Application to Local Registrar for COe.}' of Death Record PLEAsE COMPLETE FORM AND ENCLOSE FEE'......'...'. . .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~~~. First Middle Nam~~eceased First Middle Maiden Name of Mother of Deceased 'K.ok~ L.,.vKY\,C-V\ First Middle 0 Last .~l,L ..........pLEASEPR1NTOR Date of Death or Period to be Covered by Search '1 - d--O'- CrD~ 0 Last Social Security Number of Deceased ~")\L'y-~ Last b~- l~-~~7 Date of Birth of Deceased (0/- lL{ .-- ~ Month Da Age at Death Year 6V\ ~J.'\.eS ) Place of Death .~lo Q~ i))Vv~ Name of Hos ital or Street Addr~ss Purpose for Which Record is Required ~--b\~'~VS W~0~ County What was your relationship to the deCeased?\iAfi.-eV-~- cilY~ In what capacity are you acting? I ~'\.....~...p. ~-Q-~ \'\ If attorney, name and relationship of your client to deceased --- Strmll). catalano &. 1lalveX ;'J East :\lain ?treet :i Wappin~t'rS l--alls. ~.Y 12590' 1- 27-\ - , b Signature of Applicant Address of Applicant . .....COMPLETE FOR DEATHSOCCURRlNGASOfiJANI.JARY1i'196S.'>'>' '.. . ~ Number of copies requested with confidential cause of death -12- Number of copies requested without confidential cause of death .............'...........X..PLEASE"PRINt..NAMEANOAoORE$$..WI-lEREReCORPSHQui..D.aESENT........... .... Name Address City ___ State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Seclion Application to Local Registrar for Co~ of Death Record . ....PLeAseGOM Pl,.ETEFbRM AND ENCLbSE FEE . . .. ...... ... .. . . '. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased %W~ FH~ '-' Middle Name of Father of Deceased ~ ~~ Last .......PCEASE.PRINT OR Date of Death or Period to be Covered by Search Q)'-1 - l '1-- 6-01 D ~I~~ First Middle 'tast Maiden Name of Mo.ther of Decea~e<\. ___ \j. ~J.lo- ~ ~\..AS\lJ First D - v Middle Last Place of Death... _ \ \ ~ CJ?\ ~L\..o.-V"YYl.D ~vlUj Name of Has Ital or reetAddi:es Purpose for Which Record is Required \.J~ w.e) ij~ Social Security Number of Deceased o'1,~ r l ~.- ( ~":Yo Date of Birth of Deceased :::r ,- s - d-~ Month Da Year Age at Death ~_. l0~~' Village, ~ or City cas- Dd-J~) County What was your relationship to the deceased? 4\...LM:1..Q. ~y-- In what capacIty are you aC'IOg? tJ'v-- ~.~ ~ tt attorney, name and retationship of your client '0 decea d - \ Straub, Cdla[cltlO & llalvey 3" bJst :\lain Street Signature of Applicant Address of Applicant Wapping~rs Falls. :,-:y 12590 ,j ~~W\'PO~APmS6R I -;:-ffl~~M:c[eRK ._.........r. .:_I.'-:..~e:....~_._._~.:.~-;... 'cOMPLETE FOR DEATHS OCCURRING AS OF JANUARY 1 .. ....'.. . . .........)pl.eAsE.PRI NTNAMEAND,AODRt;;SSWHERERSCORDSHOULOaeSENT Name ____ Address City ___ State Zip Code DOH-294A (6/2000) .........- NEW YORK STATE DEPARTM ENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ...........................p....t.....e...A,....s....s....c.....O...M.....P....t..S....T...e...p...O.....R....M.....A....N.o..e...,.,...c....u.O....s...S.....F..e...s............. ..... -...........--....,...-. -...... . -.. . . . "'. .. . -. ... ........-.-. . ...., ,.-.... .- ... .. .... "' ... . .... -... .. ., -.. . -.. . .... . ...... ..., ." :">:::<<<<<<< >: .-:-:--:: : ,.:..'.,: ..:.: ):":::>:::"" ,", :",;:::, ,":": -: :<<.: >. .::::-.':",,: ,:;,,:, ......:< :::.:...:..: .->./..::. .:. '::->::;" :':.;.:":..:.,: .,: .::.):-..;:;..: :'" : }}< . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased r\~ p.. First Mi.ddle Name of Father of Deceased VMZ,//t:Jrri- SL Last Date of Death or Period to be Covered by Search 1/rj; v Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last First Middle Last Place of Death ."" I.jz. Q-c--s"Zv1Cy' \~( . Name of Hos ital or Street Address I Purpose for Which Record is Required Date of Birth of Deceased b <6 3"3 Month Da Year lAJ"I1(}II~UC M Its . Villa e, Town or Ci Age at Death 7-7- Du'J"0h;:S5 Count ~1J-0 ,--. c... t/1 What was your relationship to the deceased? r:G6G'Z O!/;f.,'Z!L In what capacity are you acting? b'W C-:1Vl-lZm~ If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant T~~~ Dale~o 1<(; 0 [)... . \ V1I<5r;rz...... ~-1Il<) / .................................................,........................... ....................-..... ....... ..-.. ............... ............... )nn.)nn........nnn.).COMFr } .:.:.:.:.:.:.:.;.:.:.:.:.;.:.:.:-:.:-:-:.:-:.:-:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.;.:-:.:.:::.:.:::.:.:::.:.:.:.:.:.:-..'.'."" . ..:.:.;.:.:-:-:.;.:.:-:-:-:-:<.;.:-:-:-:.:-:.:.:.:-:-:::-:-:-:.:-:::-:.:-:-:.:-:...:-:........... ...............-........... ...,........... ................................. ....... ............................. .. ....... .............., ........ ...................... ..... .. ........ ... ............ - Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death )...........n.n.n..nu...upul;4$ees.NTNAMIANOUdselfilWtlEBSiAEQQIQlaOUt.;O.$ESEN1t{..n}}i/............................ Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COI!Y of Death Record .. .....PLeASE;COMPl..ETEFORM .ANDENCLbsEFee'...... . '. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .... .....'Pl..EASEPRINT OR Name of Deceased \-erd \Y1a.\r)c.\ First A. Middle \faV12; l \sf\q, Sr. Last Date of Death or Period to be Covered by Search ~p' 9,20\6 Name of Father of Deceased Fr-C\.V1k First Middle \la.V12 I'l bt1q Last Social Security Number of Deceased C)5 I - 2(0 - Y-=f 3( Maiden Name of Mother of Deceased *nVl E?or('e[ (1 Firs Middle Last Place of Death ~ z.. -erc~ \:::(-\ ,,~ Name of Hos . I or'St/eet Address Purpose for WhIch Record is Required , End ~ Date of Birth of Deceased '-.J U-Vle.. 1<8 I ~9 2> ~ Month Da Year Age at Death T=t ~'^-"\ c..~~s.. County L;-k Af~iC FtAlAe ~'3- \ D\ \<2.C~ What was your relationship to the deceased? In what capacity are you acting? ~ ~JrJq \ += <'S~ ~~ \I,j If attorney, name and rei hip of your client to deceased COMPLETE FOR DEATHSd6CURRINGAS" L~\ I Date ~I l2f31b Signature of Applicant Address of Applicant 10 ~/ umber of copies requested with confidential cause of death .. .. ""Pt.EASE'l?fUNtNAMeANDAO[)RE$$WHER~ ......." . .."...-........ ... ,."...... ........... . ...................-..,.. .. """. .....'........... .,'. .. ".. .. .......'. ,..,............. . . . . . . , ,. .. . ...... ... ... ...... . .. .... --- Number of copies requested without confidential cause of dea Name Address City ___ State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Albany, N.Y. 12237-0023 Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send Date of Death or Period to be Covered by Search Mathew J. Augeri First Middle Name of Father of Deceased Last September 21, 2010 Social Security Number of Deceased Joseph Augeri First Middle Last Maiden Name of Mother of Deceased 126-16-3131 Date of Birth of Deceased Age at Death Nancy DeAndria Middle Last January 16, 1928 82 Elant at Wappingers Name of Hos ital or Street Address Purpose for Which Record is Required Wappingers Falls Dutchess Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~< ~ Address of Applicant 895 Route 82 , P.O. Box A Hopewell Date qful tD Junction, NY 12533 Co ~ ~~U:des wd~n co..u~ of cUz.od-t- Name McHoul Funeral Home Inc. Address 895 Route 82, P.o. Box A City Hopewell Junction State New York Zip Code 12533 DOH-294-A (7/92) cff'rn VS-34D NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Name of Deceased Maria DelaPaz First Middle Name of Father of Deceased Francisco Ruiz First Middle Maiden Name of Mother of Deceased Esperanza Alvarez First Middle Place of Death 22 Spring St. Name of Has ital or Street Address Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement of the deceased PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search Ruiz Alvaraz September 4, 2010 Last Social Security Number of Deceased Ortego Last Last Date of Birth of Deceased 1 24 1983 Month Da Year Age at Death 27 Gutierrez Wappingers Falls Villa e, Town or Cit Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship Date Se tember 14,2010 Signature of Applicant Address of Applicant 110 Fulton Ave., P COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 ) Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Address City State Zip Code DOH-294A (6/2000) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Seclion Application to Local Registrar for COe)' of Death Record PLl;SASE; COMPl.eTE FORM ANOENCLbSttFEE H , . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Na~~~Dew-~ A . h=~lina.nd A . Fllst Middle Name of Father of Deceased 1=(=-c.:tt'"\ k First Middle Maiden Name of Mother of Deceased ::Jer1r\ -;&,ri'e\ l ~ First Middle Last >pl.eASEPRINT OR V an2, \ btt<t S:r. Date of Death or Period to be Covered by Search "Cl~ \ Iot\a.~ &- Last ~-\-. 9, 20lD \l~n2-"(o~ Last Social Security Number of Deceased OS\ - ?<c - '--1'139 Date of Birth of Deceased ~ \AV)e \6 > Month Da \9~~ Year Age at Death i--=t Place of Death '12- ILV\. 'b-i J'€- Name 01 Ho tal ot...Sleet Address Purpose tor Which Record is Required r City t::u-~Y-es. c~ County 5ld of L\-~c- ~~'cs. What was your relatIOnship to the deceased? In what capacity are you acting? O{\ ~ct \-r If attorney, name and relationship of your client to deceased <:: h.~ l DCec"i-o'"L CS-P fun~ Signature of Applicant Address of Applicant \3\ 9 - \3- I D ~ \?Sj D COMPLETE FOR OEATHSbcCURRINGA Number of copies requested with confidential cause of death f?a~(f;~ilW~[5) ~-- Number of copies requested without confidential cause of d ath ", ""/PLEASe"PRINTNAME;ANDAOORESSWH SEP 1 ~ 20ID APPINGER ENT< Name Address City "________, State Zip Code (~ \~'-'f'50H-294A (6/2000) f11/U iF ~yr-&97- V?rf j-- Application to Local Registrar for Co of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. NWe of Deceased /) I. 'J Kobert rCltTIC L First Middle Name of Father of Deceasfd M I ct\ Cl~ i -Jo5CD h First Middlef Maiden Name of Mother of Deceased Made-lll'\L First Middle Place of Death . f II Crcd)4>o/t:. C' - Name of Hos ital or Street Address Purpose for Which Record is Required .. . . . . ,- '" .. .. . .. ,.. . .., .. . . :'::':',' '.:;':':', Date of Death or Period to be Covered by Search /6 I/D /~" JV1 u iCl VI Last Social Security Number of Deceased fVlorq l\ Last )~~e- /5/- J~- (}L// Age at Death Date of Birth of Deceased o ) tf /CJl/d.. Month Da Year Wt1-Pl-fQ//5 ;v. V- Villaa~, Town or Ci ) ~ Dv+CA es5' Coun )\/li'- C l G... (] 5 e What was your relationship to the de ~ed'? ~/;Il ~ In what capacity are you acting? ~ f)6 /;15 r: If attorney, name and relationship of you! client to deceased Signature of Applicant Address of Applicant .-L Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) 1 ^\(~ ~jGJrJ ~ State Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record <PLeAsl$ COMPJ.,ETEFORM ANOENCLoSEFEE........ .. ....,... ..., FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ..... .. ...... . PLEASE PRINT OR Name of Deceased ~\c:hcte\ First \J(n~ .~~ Middle Last Date of Death or Period to be Covered by Search 9-\0--\0 Name of Father of Deceased N\CV7ae\ P First Middle Maiden Name of Mother of Deceased ~~r-Jr,I'VYe- ~dc1-e- ~ I Middle Last Place of Death I Ldlk \::x-\-r~ Name of Hos ital or Street Address Purpose tor Which Record is Required .1=6. L~ Social Security Number of Deceased o~- 0(2 - l(Q~T Date of Birth of Deceased L{ - ICSl - 82 Month Da Year Age at Death 2~ 1::::u:tc-Ve~ County E=V1cl ot u~ M~~ Dr~c-m cp .~W\~~ What was your relationship to the deceased? _~V1e.f'C:)..J In what capacity are you acting? CY\ ~~ \ ~. If attorney, name al . nship of your client to deceased Signature of Applicant Address of Applicant . '...cOMPLETE FOR DEATHSOCCURRINGASOFJANUARV{198S<> ".. mber of copies requested with confidential cause of death -~ Number of copies requested without confidential cause of death . ... . ......,pLeAsE.PRI. ERE RSCORP$HOULQaI;SJ;NT':.'.".".. Name Address City ~._ N OF WAPP~~ER RK Zip Code ~-2~~jC(6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coe.y of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased J o>Je;le First Middle Last Name of Father of Deceased ~L ~tp//t.-/l1 /(7M. First Middle Last MJjd~~/Name ot Mother of Deceased q,A//Y ,41~IL/ L ~RII{' If First Middle Last Place of Death /I PI- .231 L 13~ /L ~ {t/I&~ .::: . ..::. .. ... , ';:::.::.' ',::::::',' Date of Death or Period to be Covered by Search Name of Hos ital or Street Address Purpose for Which Record is Required (!) nk: (\J :z~/'" eO Social Security Number of Deceased m 7-7?~'37o Date of Birth of Deceased -1 ) Age at Death ~th ~ ~ar c29 WIlP/~ - r ~ {C/ Coun In what capacity are you acting? If attorney, name and relationship Signature of Applicant Address of Applicant ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City Zip Code DOH-294A (6/2000) ~ TOWN OF WAPPINGER TOWN CLERK ~ ;- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coe.y of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~bGtAR.. WALU\~ First Middle Name of Father of Deceased 0++(;> First Middle Maiden Name of Mother of Deceased O(\~-\- G:\ First Middle Place of Death E: Lf\i\ST Name of Hos ital or Street Address Purpose for Which Record is Required 5e-e:rt\- Last ; ASemRRINT:Q8::;rypEIJ(::::::J::~:: fIJi::: ............. ....:~?:f Date of Death or Period to be Covered by Search '6/a /a06~ ~ LO \ \ Last Social Security Number of Deceased 07~- ~'-t-3~3D 6LO\\ Last Date of Birth of Deceased 0"1 l~ Month Da 'Cf3} Year Age at Death t?f WAPp:r'\t::..,t:-CS ~\\S Villaae, Town or Ci ~'""'+ Co. Lt Ss Coun C ~'R.. -SA-~E"' What was your relationship to the deceased~o ~ In what capacity are you acting? ~ 'j....eJ \" ~ If attorney, name and relationship of your client to deceased ~ s.. \l (J\\ c..cJ n ~s.~*- Signature of Applicant Address of Applicant ~. d~O Z. ~~ Date.xJ:l.SJ';AC ID Ll q(o ~"jO\t'"J. k>nad 1 CD r I"\~O\\\ r'J'f ) 2~1 8" - Number of copies requested with confidential cause of death .1-- Number of copies requested without confidential cause of de~th >i?:~:>}~;;~:::)::>: . .... ;:~:~n:~)Ur\PUEA$E~):eBINlt_BtiANDW..:.::DR . Name ~ €A'"",,\r\ F .. S c::c:rt+ Address l.\ q (Q p... "'a C\ \ c< t.C. D ~\ City Co ( C'\ \...0iA \ \ State N'I Zip Code 1'2-51 S- DOH-294A (6/2000) Ii~ ? ~ CD I cJ. ,"'.,,-<..,'. .' ~~_:.~~_.;;!~- "~(.. . ~ y NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. N~e of D~ceased V0t. I S vVl. First Middle Name of Father of Deceased -.. I . . . " .. .. .. . .. ... . ". .. . :.::.;.. .,::':';', : Date of Death or Period to be Covered by Search r:s- ~ CZ? \ q ~-1- Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased First Place of Death Middle Last ~1- WtqhAev Month Da Year Age at Death :;- 1-- ~y 1)~1 ck Coon VJ itPP Fwl \ ~ Name of Has ital or Street Address Purpose for Which Record is Required S V rJ \( <.. CO t.~Ye. <;' Villa e, Town or Ci What was your relationship to the deceas~~'7 In what capacity are you acting? <; ~ . ~ Jc-- If attorney, name and r nship of your client to deceased / {;V~ ~ ('"\~ ~~L Signature of Applicant Address of Applicant S' (J c-J Da-l/1Lf ( {O - Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State DOH-294A (6/2000) TOWN OF WAPPINGER TOWN CLERK --;. .. n ~ c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased A r'l-h>V'l;O .oa~,e.\ First Middle Name of Father of Deceased SOl \ II CdDre. First Middle Maiden Name of Mother of Deceased Ho~f)c;o. Rebos'i'D First Middle Last Place of Death ,?"C; ,?eTc~VV\To\..v"V'- f!-coc;l VV) 01 \V\;e (() Last :': I "", .. . . ';:; ;.::" ..:;:;::.,".' Date of Death or Period to be Covered by Search OGI (J...) I b Last Social Security Number of Deceased 00 Y -(o0-7-DI0 MCli",;e.ro Date of Birth of Deceased Age at Death 60 Month OG Da 0'3 Year Y Lj ) L-.J7"1'f~Vi~Y~(-S t=:.11~ tvlj !;1.. S-GIt> ,,0Jh k' .s5 Name of Hos ital or Street Address Purpose for Which Record is Required Vi'll W'( VV\~*r:s Villa e. Town or Ci Coun w if'e What was your relationship to the deceased? In what capacity are you acting? w ,'fe.. If attorney, name and relationship of your client to deceased Signature of Applicant ~#~ Date (){ /;"d-//D Address of Applicant ~& )CftchOl~tt>\,NlA t:ooJ, WC\fP;r1'3~rs~l\~. N'-1 Id-SqO H , , e"PRlNT'HAM" S'A"NDH' .. .... n.. .. ," .... . ,', .. ..... ,...... . .;.... . :-:', .;." '..:.', .....-. ',' ...... . ',.:.",. .'. .", - ..... Name Address City State Zip Code DOH-Tl NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Seclion Application to Local Registrar for Coe.y of Death Record .......PLeAsE;cOM pLETE FCRMANOENCLbSEFEE>q . .....:c.:...:.:.....:. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .. .q.. qpLeAsEPRINTOR "T'-' .:......:.....:... ....< ..<>:.. :... Name of Deceased Date of Death or Period to be Covered by Search H 0..1'", ~ Sm;-t-h ~-\I-ZolC-' Fils! Middle Last Name of Father of Deceased Social Security Number of Deceased --::-r~ ~ ~~ e"'l. e. V)-e. \ c.~ I u, I - Z &:> - 8z l' ~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death S+c\\q BvoZ 0;::., k \ 9-2 - I <13 I T'O First Middle Last Month Day Year Place of Death 2- c=lc<.~ M",,-~ WCA:.fP\ ~ <::r ~~heS'C:, Name of Hosp1 or Street Address Village( 10wrlDr City County Purpose for Which Record is Required L=y'l d A-~\~S o-t LiQ What was your relationship to the deceased? F-u VIP r<A\ prf<:.:.e:1-oL In what capacity are you acting? c:vI ~ VIa. I P af' ~VY\f-l:j II allomay, name and~hiP of your client to deceased ~\ ~ 9 =0 Date B~ \"2:, - I 0 Signature of Applicant . ~ Address of Applicant \=G \3a,x 12,1, W G.. fpl 0~V6 \~ \ \SI N---j IZ590 ;.-. COMPLETE FOR DEA TH-S>O:C'C-U'RRI'NG":,AS..OF"JANUARy:~:t:::;?t98Ef:;::\::::;::.:;:;:;:;::.;.:.,.-.., -." .. Number of copies requested with confidential c .:..:.....:PLeAsErPRINTNAMf;ANDAO pee.seNT> , .... ,......,.. ...... ..'.'.....,.,.-,..........",.. ... , . . . - ., . . . . - , . , , . , " ..,. . , , . , , . . ........ -.... -.. .,..,..."...-."... -., ,. .................. .-..',....,',.........,.. . .....,'.... ,... .. . ... .- -.. - " . .....'.......'-....,.,. ,., . .~.- . .. ...... ..... ....-.- ......-., --- Number of copies requested without confidenti Name Address City _____ TOWN CLERK State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COei' of Death Record ....... ..'PLEASECOMPlETEFbRMANOENCLbSEFEE... . ..... .... ... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased '~(A \ 1.<Ane>.... First Middle Name of Father of Deceased tte\ n n 'cY\ First Middle Maiden Name of Mother of Deceased t---.\o..q de1~ \1tA.e.t\ 6'"\~~ FlrtU Middle Last \J~ Last .... ._.po..... p,t.t::"ASE..PRINT'O,"R-TY:P"E/.:'..". .. ........... ........ Date of Death or Period to be Covered by Search 12, 20\ () H","~~1n Last Social Security Number of Deceased Ol.\ CO - 3""2... - Z"2.. 55 Date of Birth of Deceased ~. CQ ( l '1~5""" Da Year Age at Death ~( Month Place of Death 6Lt01- fhnc-e~ G.~ Name of Has ital or Street Address Purpose tor Which Record is Required Ed o-P- L-~~ ~\~ ~~ County What was your relationship to the deceased? ~ In what capacity are you acting? ( {2 c.v" If attorney, name tionship of your client to deceased fRi Signature of Applicant Address of Applicant COMPL.ETE FOR DEATI-lS.OCdURRINGASOfiJANUARY119SS.:::.:::.:::::......... @> Number of copies requested with confidential cause of death -- Number of copies requested without confidential cause of death . . . - . . . . . . - . . . .. . p . .. ... .:~LeASErPRINtNAMeANDAOORJ;S$WHER15iRECORt;r$HOUL.p$ESENT}:.,.... .. Name Address City _____ State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Albany, N.Y. 12237-0023 Application to Local Registrar for eoI!)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Barbara J. Webb First Middle Name of Father of Deceased Last August 15, 2010 Social Security Number of Deceased Gerald Lawson First Middle Last Maiden Name of Mother of Deceased 070-40-5905 Date of Birth of Deceased Age at Death Marie Camerano First Place 0 eath 57 Flintrock Road Middle Last May 10, 1947 63 Wappinger Dutchess Name of Hos ital or Street Address Purpose for Which Record is Required Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~ 1- .~ Date 0 Address of Applicant 895 Route 82, P.O. ~ox A Hopewell Junction, NY 12533 10 Copies of Death Certificate with cause of death Name McHoul Funeral Home Inc. Address 895 Route 82, P.o. Box A City Hopewell Junction State New Yor f!ffIJde1 533 DOH-294-A (7/92~ AUG 1 7 2010 TOWN OF WAPPINGER TOWN CLERK VS-34D NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ..... .. <PLi.\SAsE COM Pl...ETEFORM AND ENCLoSE FEE . CO... ... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Na~ Deceased c:Dt\~~ e. FJrsl Middle Name of Father of Deceased \[\' r \ First Middle Maiden Name of Mother of Deceas,d ~ E~el V\ ~~hO\ Firs Middle U Last Place of Death 3Gl Naf"11 n D-t\(fC J Name of Has ital or Street Address Purpose tor Which Record is Required .\\~~h Last .... ....... PLEASE PRINT OR Date of Death or Period to be Covered by Search I. 2c:.\O (<f1, ,'Ci Vtt- Uast Social Security Number of Deceased c, 1-0.- 2.<0 ... ~ '2;S \ Date of Birth of Deceased Wl~ ~\,'~ Month 0 Da Year Age at Death "T-:=t- L::<<-\-c.-~~ Count End a-P L\'~ Ar~\~ What was your relationship to the deceased? t--1Avre ~ \ b rec.. ~~ In what capacity are you acting? on ~ho.. \...r a-P ~m llj tionship of your client to deceased Signature of Applicant Address of Applicant Wo..FP~e~ e,-\O-\O Date \\$/ ~y \25ib Number of copies requested with confidential cause of death . -". .........-......'.... "".......................-..... .....................'.............,.......-...... COMPLETE FOR DEATHS OCClJRFUNGAS OFJAN . . --- Number of copies requested without confidential cause of death Name Address City ___ State DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Albany, N.Y. 12237-0023 Application to Local Registrar for Coey of Death Record FEE: $10.00 per copy or No Record Certification. Please d not send cash or stamps. AUG 09 201J John H. Hartung First Middle Name of Father of Deceased Last August 5, 2010 Social Security Number of Deceased Wilhelm Hartung First Middle Last Maiden Name of Mother of Deceased Charlotte M. Blumenthal Middle Last 128-24-4854 Date of Birth of Deceased Age at Death April 14, 1930 80 5 Scribo Lane Wappinger Dutchess Name of Hos ital or Street Address Purpose for Which Record is Required Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~ (/:] /YIA ~ Address of Applicant 895 Route 82, P.O. Box A opewell Date 7/7//0 , Junction, NY 12533 ~ 10 Death Certificates with Cause of Death \ Name McHoul Funeral Home Inc. Address 895 Route 82, P.O. Box A City Hopewell Junction State New York Zip Code 12533 DOH-294-A (7/92) VS-34D NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. w~olr;C;::d ;1. ;irst 'V\,,..., Middle Name of Father of Deceased ~~~ .. ..)),\]~LeASE'~RR'.... /L.. Date of Death or Period to be Covered by Search A "J / . . ..... . ...., ..'.....-.-.-.;.;-:.'...'.'...........-....,..:...-.....'............,'<.'.......;,...,...................... ..........'................'.'...'......,.........-......-..........,....,.-......,.............,...,.... ..............................................,..............-. ..... -.-,............ .................-.-............ ............................--.............. .,..."......... ...._-..."......."..,-................. ........... . . . . .. ...............,.,.. . .., , ... . . . . . . . , . .. .. ....................... .....-.-.......- .. .................. ................... .. ......... ... ~o I t? Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last J~/- 4-27 ~ Date of Birth of Deceased Age at Death (lo~ 0 &Iv /CfSdar ) J' . Vv fcke.f' > Coun First Middle Last Place of Death / I _ I. IJ I 1..1 r J.t) q 5 /Vw nalAieJ1 Stu/t 1Jd, /" J Name of Hos ital or Street Address ~a , Purpose for Which Record is Required I ~.scJr-anc e (J If / (jan ctCU/V~ fj What was your relationship to the deceased? b - . I n what capacity are you acting? 11' C If attorney, name and relationship of your client to deceased SignaruremApplican~7- J~~ 7Jji~/6' Address of Apphcant ~ ~ . 'fIe/ ~C) 3 -'-- Number of copies requested with confid~ntiaJ cause of death _ Number of copies requested without confidential cause of death . . ..... ;i';;;;PLE:4$)i;PBJI\Q:mNAMalAID.iU .. '.: . . ..i::ER&;iS ." '..8D\.: .'.UtD'ae;;$ENTJ';/J ~::ss l3;} 1f::::~ ~;je~k C;:~d,-r Urll&~ City f't/f'k~!!I$;-e, ' State~~rk Zip Code DOH-294A (6/2000)W~ ~ JUL' 2 9 2010 TOWN OF WAPPINGER TOWN CLERK ridgewav ("" ./ FfCDEHAL CHEDrr UNION July 26,2010 Town Clerk Town of Wappinger 20 Middlebush Rd. Wappingers Falls, NY 12590 Re: William A. Warg - Death Certificate To whom it may concern: Please furnish us with a Death Certificate on William A. Wargo This is needed to process insurance claims pursuant to the insurance coverage on his loans with our credit union. Gary J. ampbell Collections Officer (845) 452-3451 ext 1115 -~ \i(;;T '\~'~~( , 'IYD / ~/~ )'} i3Uf? ElT L\iD T PO G FE IE 45 8/15 52 281 TOLL EHEE 71 68 281 " wavfcu, - -- ----.-.. ~~...~---".._--.~..-~'-,.->._-~ ---'----..--..>~.-'-~--"-..-.~~-~,--.~ ,-.- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Col!)' of Death Record . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .... ......... ...... .. .........................'. ..............,.......,............................... ..........,.,.:--.................................... ........-:.......,....-...............,.......,....... .... - ,". ................ ......... ......., ?::),::t;'PLEASE( .;......; . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ..................."....... . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................... ............................... ...". ::::::::::;:::;:;::;: .... fjt~fi~ittt~~rr~rjIt~~~)fiiJeLeASe(e ," INTr.'; :. Date of Death or Period to be Covered by Search Name of Deceased ~~ ;Fi~st Middle Name 1J Fat'7r of Deceased ~ Middle Maiden ~Moth.r of Deceased :; ~ Da~.: Birth ~O:;"ed ~ Middle Last Month Da Place of~e~ I \ ~d- tu~ Name of Hos ital or Street Address I / 0 Villa e, Town or Ci Purpose for Which Record is Required ~~ kcjU~ Last 23 I z. c:: ( C' Social Security Number of Deceased ~ 239- {2.-- 9'~-27- Age at Death 7'3.t::t Year J'/-b cP~ Coun l l ~ Number of copies requested with confid~ntial cause of death . - Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) I\JEW YORI<. ~,T ATe DEF'ARTIV\EI\JT OF HEALTH Vilal RecOI'd" Sl'lctlon AppHcation to Local Registrar for Co of Death Record .PLEASE COlVlPLETEFORMANDENGLOSEFEE. FEE: $10.00 per copy or l\Jo Record Certification. Please do not send cash or stamps. l\jame of Deceased H ARo!..]) ;p. First Middle l\Jame 01 Father of Deceased HA~Lf) Fil-st Middle Maiden Name of Motller- of Deceased ANNI1 Firsl Middle Place of Death (; FRII"'KLIN ST. Wiilmc 01 Hoe-pilal or Street AcldreC's Purpose for Which I~ecord is Required PLEASEPBINTORTYPE Date of Death or Period to be Covered by Search TOML.,N S Last .J /..JIVe ;:l5, ~<) / 0 Social Security Number of Deceased 10ML/N 50 Last /1;;1- ~'-I- ~351 SI'.4c..o#c Last Date of Birth of Deceased yee. 4-, Month Day 1951 Vear Age at Death S?? t."..JJ'1,dPIIII~EI2J rr1(..(. 5 Villa~le, TGlI>Jn or City .z; UTCHe-55 County IV !?eTTLtit g-5>,A-,e What was your- relationship to tile deceased? -;: UN cJ<J.}(. .~/l2e t... 1"0 IL In what capacity are you acting? S4-rvJ.l:.- It attorney, nallle and relationship o[ your client to deceased Signature 0-( Applicant ~A~ a ~/1J1n':7 Date Address of Applicant _ 6 4- E.. 1l/1J/-1 N S_ T. Lt)I1f';?",tJGEt?~ r~ ,-'-5. IV...Y. 7- ;;nl-IO COMPLETE.POR DEATHS OCCURRING AS OF. JANlJARY11B8S. ---1-_ Number. or copies l-equesI.E!c1 with conliclential caLise or death __ l\lumber- of copies l-eqLlestElcl without confidential caUse or d PLEASEPHINTNAME ANDADDRESSWH l\jame __ Adclr-ess City State Zip Code 1A/1LLt0A_,~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record .~AND~~:ENCLOSE6&e))J.~:)J :.:.:.:.:.:.:.;.:.;.:-:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.;.:.:.:.:.:-:.:.::-;.:.:.:.;.:-:-;.:.;.:.:.:.:.:.:~ ...........................".......... ........... ........... .................,......._..._..'...._......~ . ...... .. ... .,,- FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Na~ of Dec~~ed /(.OYlQ lU . First Middle Name of Father of Deceased \pJo.l re.( First Middle Maiden Name of Mother of Deceased J t. C\ 'Il-e.... j Q \0CAS5e t..-:V~irst Middle Last P~ce of Death () ,,( o15~'~ Name of Has ita! or Street Address Purpose for Which Record is Required 'bru(Ull . Last . .::: I ..::. . '::::.;:. ..:;:;::.... Date of Death or Period to be Covered by Search l-\~-lO' ....: BnA. r\JJ\.. . Last Social Security Number. of Deceased oq3 -- 3\o~'#O~\.o- Date of Birth of Deceased q Da I Month Iqq" Year Age at Death & '3- D-k~ "toun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant L ,Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) I'JEW YORI< E;TA,TE DEF1ARTIVlENT OF HEALTH \/Ilal Recmds Eipr;trilll Application to Local Registrar for Co of Death Record PLEASE COlVlPLETEFORM AND ENCLOSEFEE FEE: $10,00 per copy 01 l'Jo Record Cer-tiflcation, Please do not send cash er- stamps, PLEASEPR1NTDR TYPE .. -c-. ..................i .... .........' f'Jamc0 01 DeceasecJ Date of Death 01 Period to be Coveled by Search HA~OLj) J) -r 0 NlLI IV.s ...) uNE ,;:) t;,-. :;}OIO Firsl Middle Last l'JarnfO' of FcllllGI of Deceased Social Security Number of Deceased HqRoJ..]) ,OIVlLIN S J/~-J-I'f- ~35'1 Fire,j Middle Last Maiden l'Jame ollv1other of Dec:eae,ed Date of Bllth 01 Deceased Age at Death RNN/1 .:5~4C.ONG JJee. AI, /'9,51 .5""8 Filsl Middle Last Montll Day Year Place 01 Death ~ FI?ANI<LIN oST. WI7~PIN6ERS FI9Lt.,.s .]) u TCHE~5 l'Jarne 01 Hospital 01 Stleet Acldre~;s Village, T-ewft. ~ County PUl'pose tor VVhlch Record is Required 70 SCTTLE ES TATE What Wde~ youllelatlonshlp to the deceasecJ':! ~cJnJ t,;l2~L DII2t"C TOf.2- In what capacity are you acting'! SrJr14i:.- If aHomey, nalTle Emdrelationship of your client to cJe,ceased Signature or Applicant ;~ d ~/~ ];. Date '7-.;;t - 10 Address of Applicclllt , (,.tj & Ml3..tf!L~..T. ;: III/CEA?5 FAlL~. IV, So:' ~ ~ <:; ~o COMPLETE FORDEATHSOCCURBINGAS OFJANUAHY1, 1988 ::3._~ NUIllI)el 01 copies lequested with cOllfidelltial cause of death --_.~. I\lumber of copies I'equestecl without confidential cause :f de~~~~U~~\Q) JUL () 6 'll.J PLEASEPRINTNAME AND ADDRESS eQ'J ... , ,uvv'" '" CLERK , TOWN I'J a ITl e ~_'__ - Add less ... City .. ._~ State Zip Code r')()I...L ':lq4A 1(,/::'00.:1\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record . .. . . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~e.5t$)~\ Last Date of Death or Period to be Covered by Search I - Lv - )(j Name f Father of Deceased L\~~){) First Middle Maiden Name of Mother of Deceased \1 ~\'O\N'$Middle Place of Death \ \ 2-.\ l\~ ~ vvD Name of Hospital or Street Addre s Purpose for Which Record is Required Social Security Number of Deceased Last 5o-lole -l pi '~ Dat~ of Birth o~eceased '-I ~ Month Day Year "~ ~own or City Age at Death (;(P ~~~ County Last 1.J>'" What was your relationship to the decease In what capacity are you acting? If attorney, name and relations hi of your client to deceased Signature of Applica t Address of Applicant Sl\ .... -_.,-.,-- ..-...,.............,........................."..'...,................."..--..'.'.....--...'..... ....coMeLE'tEFQRDEATFtSOCCURFtlNGi... Number of copies requested with confidential cause of .. ............<<.PLr:.A$E;f>fUNrNA.M~.ANJ4.P$lPRE~$NVHJ$R ...... Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. F." t Middle Maid~e of Mother f Deceased First Middle Place of Death :3 Name of Hos ita! or Street Address Purpose for Which Record is Req . 9d Last Date of Birth of Deceased Age at Death Signature of Applicant Address of Applicant Date _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) (fLU~ EWYORK STATE DEPARTMENT OF HEALTH ital Records Section Application to Local Registrar for Co of Death Record tr;,;.,;ij'r:;j';;n'lli:;;;;jt;j;;;r,tftt;:g;;jtt;:Hjii=grrtjIt;;;:;:etEASEt .,. ...., : . "'1.:' ';luer}@}:;:;F:lttjj;j;@f;:j:;::};r;rj:}tj;ff:: . . . . . . . . .. . , . .....,.................................', ..................'....................... ........'..................,......'...... ...... ...............,. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ame of Deceased ~ {onto FIrst Middle Name 01 Fal?er of Deceased ~ ~ /If (.o,:tof'L fYl C\ I~ .f\., I e r 0 First Middle Last Mai~er Name of Mother of Deceased I nz>r+el\uc... K.e....b O~) '0 First Middle Last Place of Death g- {, Ke + e t-, c.. VI^- +c,-J " ;~jt~fi~~rtj~~;@rt;m~*~mnn1tr~!i1~ji~~iimt~1~mmft~~irj@irftt~1~~~~J~~~~m~i11~;;1~~1~t~~~~~~j~1r:~r?~~R :;: :.. '. . .;~ :.:. I.::~:. ," : . ."::- .::" .: .. Date of Death or Period to be Covered by Search /1/.c;,,; f\ { e.J 0 Last .jU(l~ J dolO Social Security Number of Deceased What was your relationship to the deceased? ^ elr:.....' f..e ~~.t In what capacity are you acting? }:,..I\. Q..('c-. \ "'b\' ('I&c \<..:,1" If attorney, name and relationship of your client to deceased Signature of Appicanl~---cL ~~ Address of Applicant flY bra. Me;. fu^ . M~ I ()g " Name of Hos ital or Street Address Purpose for Which Record is Required Lt2 5c.- \. Dale t::,}-/r w \Ie. r ^ 0 v') ~ J b ~ ~ c2 , Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death :j:i:t'i1'itlllttldll'tlttW%ffe ;:: :..' .E]fRlNllNAM ._ "ji.: .... I Name ~ fllJl1f1lu';1D 1it4{(A~ f-f-r, 'fI\.JL Address ~ ?:: '-( LJe '^- VT\ 4 .\ ^ of\. V"f!- V . City f'{ + . \I fJ (\0 ^- State AI. (, Zip Code Jb.r-(",.J I DOH-294A (6/2000) \WCU~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record .... ..... .pl..ep.se C::OMPl..ETEFORM AND ENCLoSE FEE .. . .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ...j c:fJe;::n ~" First \ Middle Name of Father of Deceased ~~h First I Middle . PLeAsE PRINT Date of Death or Period to be Covered by Search ":r'2:0\e) ;r r. Last 0(0 - '9' - ZO , D +sole, Sr, Last Social Security Number of Deceased '2- (2- - 2G2 - [ <99 <.0 Maiden Name of Mother of Deceased ~0Cae- ~~ First Middle Last Place of Death E\~n-4 0.. -t W ~~I V'C\~~ ~ \ \s Name of Has Ital or Streei Ad~s Purpose for Which Record is Required c=y,d of .L\k A~\~ Date of Birth of Deceased Age at Death ow. - 2-2- - \925 ~L.\ Month Da Year L:::v.:\"c:.~~S County What was your relationship to the deceased? ~~t"b-.J D\'r~~ In what capacity are you acting? on ~ha.\.p cf2~tvI \ ~ If attorney, name and relationship of your client to deceased ____ Number of copies requested without confidential cause of death Co - 2-\ -\0 2S'90 Signature of Applicant Address of Applicant fsJ. t 1 Number of copies requested with confidential cause of death . ..PLeAsEPRINTNAMEANDADORESSWHERERECORO$ Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Name of Deceased Alice First Middle Name of Father of Deceased James First Middle Maiden Name of Mother of Deceased Minnie First Place of Death Avalon Assisted Living And Wellness Center Name of Hos ital or Street Address Purpose for Which Record is Required PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search June 19,2010 Brown Last Backus Last Social Security Number of Deceased 132-18-8401 Middle Rogers Last Date of Birth of Deceased 1 6 Month Da 1924 Year Age at Death 86 Wappinger Villa e, Town or Cit Dutchess Count The family requests this record for purposes pertaining to insurance and property settlement of the deceased What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relations' Date June 21, 2010 Signature of Applicant Address of Applicant 12524 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 6 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHE Name Address City DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Anb /\/ C First Middle N~e ~f Fatper of Deceased ~O\lv~ta( -e. First Middle Last M,aigen Name of Mother of Deceased ~rte.1\ c..~ 0- 1?ebe>S \" 0 First Middle Last Place .of De~h + \ e-6 1\ e: c..-~tA yv." ~ '" f2-6. Name of Hos ital or Street Address Purpose for Which Record is Required JI'YJ r r I'l alII ,.. er () Last .,:IJiA . i:: :.: . I .. . i..: . :. \ j:: .; :.:. Date of Death or Period to be Covered by Search ~{)t?.e /J. ;}.O \ 0 Social Security Number of Deceased ~{ Ill-enj Date of Birth of Deceased 06 6~ Month Da 17~6 Year Age at Death ~()P~~..It r fa ll~ , N'-( Villa ~. 'row'ftlor Ci lfL( ~ U\ \-c.~ Coun ~ , What was your relationship to the deceased? ^ c..fc;:;.. \. ~ r e.. Co- ~ r In what capacity are you acting? ~..e.r-CA \. b\re....c-~r If attorney, name and rielationshiP of ,our Cfb'ient t: d~~eased , Signature of Applicant j ~~ M Date Address of Applicant ~ 6 rC4.. V"\:. , utA k . 1/1' J 1\ 1<10/\ { ( 6{r'" It U JJ 10 Cr-cl ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Last Date of Death or p'eriod to "r Covered by Search ~ / a //0 . Namepof Decease,~ : I " U"J{tfh vJfivt \ First Middle Name of Fat~er of Deceased H ,'(t'A b ~t4 \~ First Middle Last Maiden Name of Mother of Deceased j) 'i- I SulLfi :r b~}J gA-' "C First Middle Last Month Place of Death)' '/ Sh<iLwwJ rk,# Name of Has ita! or Street Address Villa Purpose for Which Record is Required Le.5(-\l pftJ-G-1 PA- i-e- I Social Security Number of Deceased --- OGg-lO - ~dlJ Dat'i ?f Birth of Deceased 1\ '1 U) iCftrJ... 0 Oa Year ~"IV~ ~) ) Age at Death 90 bv ,d,ci Coon What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your Signature of Applicenl (Q Address of Applicant 3 furXYl14 IQ~c..~ ' / ! r;o Date ~ /71 )-z..~ ~ 3 ~umber of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code OOH-294A l~ ... Application to Local Registrar for Co of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. /990 Social Security Number of Deceased Date of Birth of Deceased Age at Death First / Place of Death Ib3 J:eIC/ul/J1fowl1 Rd. Name of Hos ital or Street Address Purpose for Which Record is Required I W4'fJp.<11J/1S (!au/f)) Villa e. Town or Ci ))Lrfc:.A~ S 5 Coon What was your relationship to the deceased? dt? (-' j ~ fr ~ In what capacity are you acting? Cl1 (/ 5 f; ff ~ If attorney, name and relationship of your client to deceased Sign...re of App~cont ;Cf;;r; c1 a-nt AU J ~ d-h A. < Address of Applicant , " b-u ~ J J( d ' Date ~,/ IY,//{) t.t J. '-:/-' ,'. ::" L Number of copies requested with confid~ntial cause of death fR1~~~a\,#~[Q) _ Number of copies requested without confidential cause of death Address City State Zip Code DOH-294A (6/2000) , ~~~~~:"~~~~~) / NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record 4 ....... . ........................ .....'.................. ..... ..."............ ...................... . , ,. . . . . . . . . . . . . . . . . . . . .....-................. . . . . . . . . . . . . . . . . . . . . - . . ..-....,............,.. . - - . . . ' . . . . . . . . . . . . . . . ......................... .;,..;.>..;.;.;.;.>>;.:.:->:-:.;.;.:-:.;.: . ................... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased mavLf First Middle Name of Father of Deceased D~(Wl'1 I First Middle Maiden Name of Mother of Deceased l^" 'A-I/U D(A v:\.vte-tf. V T I First l q U Middle Place of Death 3d- V:-V\ l-\-on ~ vjVJV\eH- Last ~'(?~fV\ Social Security Number of Deceased Date of Birth of Deceased Age at Death Last Month Da ( d ~~t[) 5-\ L ~ P~)( (\l. Rr'S ~A-~ is ;"-1. y -Ztl Name of Hos ital or Street Address Purpose for Which Record is Required P-et!O\f 6 What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relations ip of your client to f3' I TOWN OF TOWN Signature of Applicant Address of Applicant .. ..' l Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2~.\ . /' . tr .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Albany, N.Y. 12237-0023 Application to Local Registrar for COPY of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Sarah M. Pecoroni First Middle Name of Father of Deceased Last May 30, 2010 Social Security Number of Deceased Brook Last 064-40-0223 Date of Birth of Deceased Age at Death Flydacosta Middle Last February 5, 1918 92 11 Scribo Lane Wappinger Dutchess Name of Hos ital or Street Address Purpose for Which Record is Required Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~-{,\ ~ Address of Applicant 895 Route 82, P.O. Box A Hopewell Date fo/I/lu Junction, NY 12533 4 Death Sertificates with Cause of Death {R1~~~U~~\Q) Name McHoul Funeral Home Inc. Address 895 Route 82, P.o. Box A City Hopewell Junction State New York Zip Code 12533 DOH-294-A (7/92) VS-34D ... NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Applic fo to Local Registrar ord ..IilFU;;."FOA.ANDIiSNC.. .... FEE: $10.00 per copy or No Record Certification. Please do oT@WHSOff WA~PINGER Name of Deceased $~.JJil2.b c. ~'(/IJ..~G"S First Middle Last Name of Father of Deceased Date of Death or Period to be Covered by Search 10 /~.r 2..OD~ Social Security Number of Deceased First Middle Last Place of Death - IS- HIe,.&) ~ ~It... Name of Has ital or St;eet Address Purpose for Which Record is Required o ~- /~- O~'o/ Date,of Birth of Deceased /I -:l/I'tz--l-- Mon Da Year W~f.'.:f~or~tr '/ Age at Death First Middle Last Maiden Name of Mother of Deceased 8.3 t1 Coun ~ What was your relationship to the deceased? S ~ A,../" In what capacity are you acting? S" CJ I"\J If attorney, name and relationship of your client to deceased Signature of APPlicant~""'7~ ~ Address of Applicant ~~~ ()A., t.~" . .r~ e;:> Date 4/~., ~ ~ .. -2 Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death p....eA$EPaIHrNAMJi:AHO.DRes.~u'HeRER~RO$ffl)Ol;;.aE$$$t-/ Name Address City State Zip Code DOH-294A (6/2000) ~.. ~ l I I I I . l/'7;77: .. Application to Local Registrar for Co of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased J oJ. {' First Middle Narnn of Father of Deceased l<of\o-\cA First Middle Maiden Name of Mother of Deceased ,..,-, r-f2;{\c--: n e.- First Place of Death d \ '-\ ~e,\ 5e-oI Cu 1.\ Name of Hos ita! or Streat Address Purpose for Which Record is Required \0 S(J)MI-tto S~rro 1e,s G~ V L~.ieJ ~14er:s of lfolffl,hJ0h c- What was your relationship to the deceased? . fA -\-+or f)e ~ fur J 6 c{ ;- ..s e e- T ~ PC eck-, 1- Inwhatcapacityareyouacting? Ot +-to(/l.e~ Po/' S'co-\-tSee-j Uf_ \ olc-cecl~i '5 50'\ If attorney, name and relationship of your client to deceased (f?,.SM-t vl;er-; CA. .son )0 ()() _ Kev,~ -I. """"'1' L~w efr ,,,", 0 .s~ frl.Melel Signature of Applicant l ~ DaI8 S I d. J I J 0 Address of Applicant 31-\ uoss Dr, ~ P.hI~eoJc. Nt.( 1.9<;-' ~~' Date of Death or Period to be Covered by Search T s~ Last l'd IS! K;%(lJe/) Last Social Security Number of Deceased OS l -'1 Middle Date of Birth of Deceased br~~ l~ (1,/ Last Month Oa ~. ~W\ of WCtPPI'(),~e/ Villa et Town or Ci Year Age at Death sLj [) C-1 +ck~ Coun d Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death ;~:~~?trHfrrjrrt> ~ftfiHm:Ur~~I~~~ ;.:: ::: .', E::: .:.~ : Name \( ~.V) J. RlA{tjS,e\I' t:~ -) Address :)L-\ ClhS <; {r, JI City (2... k\ I'P ~~ \ LCl.tJ (<)fPl~ o-? S~ 1"\. (~el/eLI I State rJt{ ZipCode J dS-7~ DOH-29~6/2~~~) I~--- \../ .. The Law Office of STEVEN M. MELLEY Attorney & Counsellor At Law 24 Closs Drive Rhinebeck, New York 12572 Tel.: Fax: (845) 876-4057 (845) 876-5745 Practice Limited To Injury Law Since 1983 Laura S. Espie, R.N. Diane McCaig, Paralegal Josephine Caccoma, Legal Assistant Jade H. Platania, Esq. Managing Associate Attorney Kevin J. Rumsey, Esq. Associate Attorney May 27, 2010 Town of Wappinger Attn: Town Clerk 20 Middlebush Road Wappingers Falls, NY 12590 RE: Jodi See Date of Birth: 12/27/1955 Date of Death: 12/31/2009 Dear Sir/Madam: The undersigned hereby requests 2 certified copies of the Death Certificate of Jodi See for the purpose of providing information to the Dutchess County Surrogates Court for Limited Letters of Administration. I have enclosed a check in the amount of $20.00 payable to the Town of Wappinger together with Form DOH-294A and a self-addressed postage-paid envelope for return of the requested documents. Thank you. 7t KEV . RUMSEY Associate Attorney Enclosure ~ ,~ , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record ..MPf4nSF:oa".NDENCtQ$E$FEe}. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~;:}rf'~ ~.O v!t.t;c:S First Middle Last Name of Father of Deceased Date of Death or Period to be Covered by Search ~ ~ 1-. Lc::>o I Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last / / t" - 2- 2--.. 5-<7 ?' Date of Birth of Deceased Age at Death First Middle Place of Death Is /l,./t' c....? / E DIt... Name of Hos ital or Street Address Purpose for Which Record is Required Last Month . Oa Year W/17'~a.;)~r Ci ~ nb J". ~ ~~,-- What was your relationship to the deceased? ~ O,/\..J In what capacity are you acting? 5'" t!)"\/ If attorney, name and relationship of your client to deceased S -& 73~ ------- Date ,s-. ,u--rv ignature of Applicant ~ Address of Applicant ~ ". ~~- P 1l...1(/t? W?Y" /..".. ~ 7 ~'u1" _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death MAY 2 7 2010 Name Address City State Zip Code DOH-294A (6/2000) I> -; ~ " NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar of Death Record .....-. ....., . . ....-.....-...;...:-:...;.;.:.;.;.:.:.:.:.:-:-..;.:-:.;.:..::.:::::::::::::::::::::::;:::-:-:.:::.:.:;:; " ..................'................'..-........;.:......;.:-:.;.:-:-:.:.;.;.;.:::-::-:::.:::-:::::::::::::;: FEE: $10.00 per copy or No Record Certification. Name of Deceased -- 5vfl\I\J -+- First Middle Last Name of Father of Deceased i/./) C- e- 0 f2 ~ .e /-fl (,~ "C- Y First - Middle Last Maiden Name 01 Mother of Deceased l\ J:e 5 S( ~ U 0 0 1) First Middle Last Place of Death ~ 3. kJ~ ,{ t J (lJafvUl f [,N r Name of Hos ital or Street Address Purpose for Which Record is Required f1~rtb~ Date of Birth of Deceased 1 20 Month Da /lope w4-(( f"'NC-7/0r.l o 7t-{ ..- 3 'f -15;;9 y( Year Age at Death b8 /v7 D <..I r{lC 12. .:; 5 /'0 Villa e, Town or Ci Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to ~ Signature of Applicant ~ 'f) Address of Applicant ~ 91 He L-eIf;J FrU.e-. v'o/V/~e/l S I L.e~/l L rL-(,A./~ a,p L , (r... ( 12 {! c: T6 cr"" 5(<-71/0 Date 10 70 r tJ,/ -5- Number of copies requested with confid~ntial cause of death . _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send Name of Deceased ~ .11- l 111. r..p '- -.1\ ,") L.O.. W V (vtdl Z~ v\lUCt \?L^- TI ~ ~ First Middle Last Name of Father of Deceased W~rveV\ ~)k First Middle Last Maiden Name of Mother of Deceased -' A Dolo }( ) JJt C1 e: s onC\..K.. First Middle Last Place of Death Social Security Number of Deceased Date of Birth of Deceased 00 22- s-o; Month Da Year Age at Death Name of Hos ital or Street Address Purpose for Which Record is Required +0 cLoy ClCCCtAcv-\- ub VVl~ What was your relationship to the deceased? VI V . CJL In what capacity are you acting? If attorney, name and relationship of your client to deceased TUNV' Db WLlrf\'~t1 Villa e, Town or Ci ~-klA_OS) Coun Signature of Applicant Address of Applicant ~~J~ Dale 5/7-<;/10 r '21 N Jl;0V- S\- ~K'M(Q Of~ ~ ~ '( (( (0 oj ~ Number of copies requested with confid~ntial cause of death . _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) City of Poughkeepsie, New York Office of Vital Records POBox 300 Poughkeepsie, NY 12602 Telephone: (845) 451-4200/4203 Fax Number: (845) 451-4239 . Monday to Friday between the hours of 8:30am to 4:00pm (est-eastern standard time) **Allfax orders must be in our office before 2:00pm (est.) Our mail/eaves at 3:00pm (est.)** Application for Transcript of Death Record $10 FEE REQUIRED FOR EACH TRANSCRIPT REQUESTED, PAYABLE BY CASH, MONEY ORDER, CERTIFIED CHECK, OR VISNMASTERCARD WE DO NOT ACCEPT PERSONAL CHECKS Today's Date r[ L. r{J o. DC) 'B 5 ) .~z 1 s-9 " Name of Deceased: Lcu,.()'(~ BCl'ph's+e. Date ofDeat~: UL W C z. f7. .11> .-~ # of Transcripts requested: 1 Place of Death: City of Poughkeepsie limits, Vassar Brothers Hospital, Eden Park Nursing Home, Or River Valley Care Center Purpose of Request: \ i's kt:l Cl> l1eYlt -h c..i'a.10V1 M ~V 'Sl? avdC Ace 0 ~ I ~oi1uY How are you related to Deceased:-llit~ ... 111/~~J.( . j l rJ { I ^ . -" J"f . ^ J ^ ~ (!{ CC~. Name of Applicant: lA. l v\ t-ttKy \.VI. V \...Q..Q....-c Address and Telephone:02L tJ. ~Y\\cl~Jt. 'PCM~S L.t rili l Lb 0 I Year: T d '6o..Y\ '(.. . Cl~ ~ Dc VlV\CL l1u..y ~( l S' <65 SCM.'hn. Road 'Pc> \L N'/ l~a r For office use only: Registration No. fa"x: S4S--Lf52~(Ollr rVi. : Lf3 \ - (0 I 0 (0 Issued By. Method of Payment: Cash/Check/Credit OS/25/2010 14:25 84545251188454526118 TD BANK PAGE 01/01 TO Bank FAX COVER , " TO: -~ FROM: PHONE: k 845-431-6106 DATE: 5-OlS-IO' PAGES (INCLUDING COVER): ) RE: FAX#: &98-/f1& cpk'(!!&M. -rlJanL CONFIDENTIALITY NOTICE I..f)~~ THIS COMMUNICATION IS INTENDED ONLY FOR THE USE OFTHE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAtN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL OR PROTECTeo FROM DISCLOSURE UNDER APPLICABLE lAW. IF YOU ARE NOT THE INTENDED RECIPIENT. ANY DISTRIBUTION. DISCLOSURE, COPYING OR USE OF THIS COMMUNICATION OR ANY OF ITS CONTENTS IS ST~lCTl Y PROHISITED. IF YOU BELIEVE THAT YOU HAVE RECEIVED THIS COMMUNICATION I N ERROR. PLEASE CONTACT US rMME01ATEL Y BY TELEPI-IONE SO TIoiAT WE. CAN ARRANGE FOR IT TO BE RETURNED TO us AT NO COST TO YOU. TD Bank - America'. Most Convenient Bank Hudson Plaza Branch Fax: B4S-45U118 2585 South Road 'I NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record . . """, . ::;::::;:;::;;:;:::;:::;=;:;:;:::;:;:;:;:::;:;:::;:::;:;::::::::'::;:;:;:;:::::;:;:::;:::;:;:::::;:;:;=;= .. . ..... ........,..,..............-...... . ..... ................. .. ...... ............ .. .... ........... "................. .........".,...... . ....'............................... FEE: Name of Deceased I ;J:e/V2e t;f;e/1/?e Vtlt:tJ t.L ~ S First Middle Last Name of Father of Deceased 1/J/14J,. / /C< (' C/;~/S'-!/a/l JULUl-A-' -..) First Middle Last Maiden Name of Mother of Deceased /YJ Date of Bjth of lfeceased ;&/'lee /'ldU',e~S.f'e...- C; / c:( // ~ 35 First Middle Last Month Oa Year P:?iOfJ;:;~fO/0 ~/dLe) W~/ye/2f h/4/A/Y/2SY't) Name of Hos ita! or Street Address Villa . Town or Ci ~ i ~::z,oar ov~ by Seasch Social Security Number of Deceased /;Q9- 36 - /~~? Age at Death '7 3 ~;(:. ~~~ss Coon Purpose for Which Record is Required Se/+ What was your relationship to the deceased? S4JtJV~ In what capacity are you acting? ;:.X?!?CU~;e If attorney, name and relationship of your client to deceased SignabJ.. of Applicent cd/AU ~ Address of Applicant Date "j~/ d- f J J 0 _ Number of copies requested with confidential cause of death 3 Number of copies requested without confidential cause of de~th :':,.jBE? . Name Address City State Zip Code DOH-294A (6/2000) , I\lEW YORI< ST.b.. n=: DEPARTMENT OF HEALTH Vital R ecmcJf, Section Application to Local Registrar for Co of Death Record PLEASE COMPLETEFORM AND ENCLOSEFEE FEE: $'10,00 per cor~y 0/ 1\10 RecOId Cel'liflcolion, Please do not send cas I\lam(~ 01 Deceased PLEASEPRINTOR TYPE Date of Death or Period to be Co ~-- ;;. I - , 0 OLGA Fir~;t fVliddle I\lame of Fatllel' or Deceased ..JO H N First Middle Maiden I\lame of Ivlothel 01 Deceased /L1,q/l.'E I V~CIL() Fllsl Middle Last Place of Death k" (Z \ S 1< 0 Lac;t SOCial Slc)curity Number of Deceased LIH<6.S~1 Las t (5 9,;J - I g -.5".2 4f2.. Date of Bilth 01 Deceased I i ~ E 13, i'$', I Month Day jqJ). " Yem Age at Death 8~ ~ SI-IERWooJ) )./("T~., WA-,ol"lnJ6 ~t2s FIJLL$, Name of Hospital 01 Street Addre",:; ~, TaWil or~ PUI'pase[ol Which Record is RequirE'd j?UTc:..Re<;S COUllty 70 S€TTL-€ ESTA'Tt' Wlklt wac; youl relationship to the deCf:.'ClsecJ'l Fe ,rJf'.(c'4C- .:PI J2.€'LTDI':- In what capacity arE' you acting? SAMC- If attorlJeY, nalllE' andlelationsllip of your client to dc;ceased Signature erf Applicant _~ &~o1dA.t~ Date ..6--,:U -fa Address of AppliccIrlt_~~/l1A,tJ 'f?I, lUA P.%uvc;...&12S F41 L So 11./'1 I COMPLETE FORDEATHSOCCURRINGAS OF JANUARY 1,1988 . . 5 Numbel ul copies I'equestecl with confldelltial caUse of death [\lumber oj copies lequested without confidential cause of death .. PLEASEPRINT NAME ANDADDRESSWHEREHECOHDSHOULDBE SENT .. I\lame Addl'ess City State Zip Code nnH_ ?q4A {c,!:-'nnJ\ ~ Application to Local Registrar for Co of Death Record .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ....,.-....................... ....., .............-.......... ... ..-...................,.....,........ ...................... . '" d.... ..... ................... ........-.......... .....................:... : {,PLEASEt........ ,- ... . . .... .' ., .. ... :.:.-.;.:.;.;...:...:.:...:.....:.;.;.:.:.:.:.:.:.;.:..':"'.-:': FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. (:..:...;: :t. R,dtJ. rJe;, Dale of ~ 7/ r a-tooi 'Overed by Search Last I' Social Security Number of Deceased ~3/-3g-3300 ~ Last Date of Birth of Deceased M~h I ~a ~y Q re s /933 Year Age at Death 1J Q1 kYAe55 Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship o 5 Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State ~ MAY 1 7 20'0 TOWN OF WAPPINGER TOWN CLERK DOH-294A (6/2000) -.