2010
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for co~ of Birth Recordl
First Middle Last
Name~6 ~ (avL ,5ow
Hospital (If not hospital, give street & number)
Place of -
Birth fr1 tt.. 'r)(...Q. I 5 t y~ 'f' '1'
Date of Birth ~ lcl.Z! L.LJ.fU12J
MMDDYYYY
(Village, Town or City) County. A 55
W"-fP-<'1\d-e.Y5 F4//5 a Ie .('
First
Father ~ l
C 6..y L
Middle
f
Last Maiden Name First
1) y So r- of Mother MtJ.. ry
Mjddle Last _
J:. C -e, 1- e S re:-
Number of Copies Requested
)
Enter Birth No.
if Known
Enter Local Registration
No. if Known
o Passport D Working Papers 0 Welfare Assistance
o Social Security-Retirement 0 School Entrance 0 Veteran's Benefits
Purpose for Which o Social Security-SSI 0 Driver's Ucense 0 Court Proceeding
Record is Required o Retirement 0 Marriage Ucense 0 Entrance into Armed
(Check One) o Employment Forces
L 0 5r
o Other (Specify)
NAME
What is your relationship to person whose
record is required?
o Self 0 Parent 0 Other. specify
Telephone No. (LW) LWUW
Social Security No. UlJ-W-LLW
~J
State
Zi Code
DOH-296A (11/94) Page 1 of 2
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
Application to Local Registrar
for COe)' of Birth Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Name <(; e.. ('D.. C
Hospital (If not hospital, give street & number)
Place of
Birth hJ €- G .t-
First
Ovt h 3- I
Middle Last
Last
all
Number of Copies Requested
I
Enter Birth No.
if Known
Enter Local Registration
No. if Known
Purpose for Which
Record is Required
(Check One)
o Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
I]f Other (Specify)
Working Papers 0 Welfare Assistance
School Entrance 0 Veteran's Benefits
Driver's Ucense 0 Court Proceeding
Marriage Ucense 0 Entrance into Armed
() For~es I I
~0ri C{ft?:~t
an
What is your relationship to person whose
record is required?
IXf Self 0 Parent 0 Other, specify
Telephone No. (~~~
Social Security NO.Wi1!i~
Date
ld1m~
MM DD YY
If attorney giV~~wm~P of
client to p rso~~~hfirnquired
AUG (\ 2 10::1
(name of c i~~~OWN CLERK (reJa onship)
DOH-296A (11/94 ) Page 1 of 2
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