2009
I\JEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
PLEASE COMPLETEFOHMANDENCLOSEFEE
FEE: $10.00 per copy or No Record Certification. Plea,e do not send cash or sta'J!?CE:IVCL
DEe
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Name of Deceased
Thomas E.
First Middle
Name of Father of Deceased
Thomas
First Middle
Maiden Name of Mother' of Deceased
Mildred Jennings
First Middle Last
Place of Death
4 Brown Ave ., Wappingers Falls, N.Y.
Name of Hospital or Street Address
Purpose for Which Record is Required
PLEASE PRINTOR TYPE
Date of Death or Period to be Covered by Search
Rogers
Last
Dec. 17, 2009
Social Security Number of Deceased
E.
Rogers
Last
106-34-7080
Date of Birth of Deceased
Sept. 14, 1943
Month Day
Age at Death
66
Year
Village, Town or City
Dutchess
County
To settle estate
What was your relationship to the deceased? Funeral Director
In what capacity are you acting? 5';rll11P.
If attorney, name and relationship of your client to deceased
Signature of Applicant ,j~ a. ~ . Date
Address of Applicant 64 E. Main st., wappin<fkrs Falls, N.Y. 12590
f)p('!
?1. 2009
COMPLETE FORDEATHSOCCURRlNGAS OF. JANUARY 1. t988
~ Number of copies requested with confidential cause of death
_ Number of copies requested without confidential cause of death
.
.... PLEASEPRINTNAME '.ANDiADDHESSWHERE'HECOHDSHOULDBE..SENT
'.
Name
Address
City
State
Zip Code
nnH-?q4A IFl/?OOO\ J M
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Albany, N.Y. 12237-0023
Application to Local Registrar
for CollY of Death Record
FEE: $10.00 per copy or No Record Certification. Please do not send cash or st~t 2 , 2009
Jerry Leonard Scheffler
First Middle
Name of Father of Deceased
Last
December 18, 2009
Social Security Number of Deceased
Arnold E. Scheffler
First Middle Last
Maiden Name of Mother of Deceased
103-24-1045
Date of Birth of Deceased
Age at Death
Margaret G. Finkle
Middle
Last
July 23, 1931
78
9 Fenmore Drive
Wappinger
Villa e,Town or Cit
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. ox A Hopewell
Date
Ivjt'lja1
NY 12533
Junction,
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)
J/Y7
VS-34D
NeW yuM< STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
.........,...........................,..........................,..
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RECEIVEI.J
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
DEe 1 6 2009
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First Middle Last
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Name of Hos ital or Street Address
Purpose for Which Record is Required -.
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~ . J . Date of Death or Period to be Covered by Search
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Social Security Number of Deceased
Date of Birth of Deceased
01 .2-2> . Lo~
Month Da Year
Age at Death
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Coun
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Villa e, Town'cJ(Ci
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In what capacity are you acting? M.~
If attorney, name and relations' your client to deceased
Signature of Applicent . u&
Address of Applicant
Date @ l2-. \lo '0<,
_ Number of copies requested with confidential cause of death .
~ Number of copies requested without confidential cause of death
Name
Address
City
State
Zip Code
ij
DOH-294A (6/2000)
\/<b
12-08-'09 15:03 FROM-Dietz Law Offices
~ QzrTl<f7 y
1-845-454-4966
T-;j4l:l r'~~l/ldldl t'-Ql::t
NEW YORK SlATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
FEE: $10.00 per copy or No Record CeftifjcatiOn. Please do not send cas\'1 or ~p6.
Name of DeceasGel ed
L-UCJ C? 1- ~
First 1 Middle Last 0/ ~\.CJ ~
Name 01 Fet' of oeclNlS8Cl ~ kM - 8eouriIy Numbor of o..c:-ed
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. What was your relationship to the dece8:sed?
In what capacity are you acting?
If attorney, name and relationship of your client to dece8&8CI
Signature of Applicant
Address of Appl'
Number of copies reqUfited with confidential cause at de8Ih .
__ Number of copies requested without confidential cause of death
State.Dt .A
\
Zip
DOH~294A (6/2000)
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Dutchess
County
Department of
Mental Hygiene
William R. Steinhaus
County Executive
Kenneth M. Glatt, Ph.D.
Commissioner
9 Mansion Street
Poughkeepsie
New York
12601
(845) 486-3700
Fax (845) 486-3727
December 2, 2009
Wappingers Town Clerk
20 Middlebush Road
Wappingers Falls, N.Y. 12590
~~C~/II.
i1t:'C 126
" OJ
?-') 2009
1.1141
Cl.S~/_
RE: Donald Nason
Date of Birth: 3/20/62
Date of Death: 11/24/09
Dear Sirs:
Section 45.19 of the Mental Hygiene Law requires the reporting of all
deaths of patients in mental hygiene institutions and facilities with operating
certificates from the Office of Mental Health, such as this Department.
In order to complete the investigation and reporting of the death of
Donald Nason, residing at 24 Delavergne Avenue, Wappingers Falls, N.Y. 12590
and a registered patient of this Department, would you send me a copy of the
verified transcription and the death certificate of the deceased immediately.
Thank you for your cooperation.
Sincerely,
duclc/Ud! ~j/Lv @
Richard Miller, M.D.
Medical Director
RM/kf
\- Lic-+
L- ~
cay,
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
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FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Name of Deceased
S/;.vo; /Y}
First Middle
Name of Father of Deceased
~ t? P)I .f.7o ,I';''? //:j Jv.J /.:::. /
First Middle Last
Maiden Name of M other of Deceased _ tJIt;',. -
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First Middle Last
Place of Death
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Name of Hos ital or Street Address
Purpose for Which Record is Required
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Last
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Social Security Number of Deceased
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Date of Birth of Deceased
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Month Da
Age at Death
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Year
VI
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Villa e, Town or Ci
Coun
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What was your relationship to the deceased?
In what capacity are you acting? A.::-v -.....h'J ,.....ry
If attorney, name and relationship of your client to deceased I
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Signature of Applicant ?7z...~ ~/OC...-.;!!"'~~
Address of Applicant :).. '-7 /./C'-J::>//:.7c.:.. ~ J ~c, ~. A......7
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Date
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--'- Number of copies requested with confid~ntial cause of death
_ Number of copies requested without confl~ential 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 COe)' of Death Record ____
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Name of Deceased
FlV>rN C\ 5 t:- .
First Middle
Name of Father of Deceased
FEE: $10.00 per copy or No Record Certification. ~~6 do not send cash or s~ECEIVELJ
NOV . 0 ;~..J
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Date of Deat la~Jiod to be Covered by Search
'01, '5" !DCf - 10 III loCI
Social Security Number of Deceased
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Last
First Middle
Maiden Name of Mother of Deceased
. Last
Last
Date of Birth of Deceased
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Month Da Year
Age at Death
First Middle
Place of Death
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Name of Hos ital or Street Address
Purpose for Which Record is Required
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Villa e, Town or Cit
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If attorney, name and relationship of ~o~~i.ntlf de,,:," ~
Signature of Applicant ,..-I lf1Lavif'r-(~
Address of Applicant .5P\'vAPrIl'l ~EJl. I gM\J)1)\....€.AtJ~\-\- PJ)
Date II Is!)/ rJC1
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Name
Address
City
State
Zip Code
DOH-294A (6/2000)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Coey of Death Record
FEE:
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$10.00 per copy or No Record Certification. Please do not send cash or sta. mp~
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Name of Deceased
L [. r)l'l~ r J # ~"e S
First Middle
Name of Father of Deceased
Last
Social Security Number of Deceased
First Middle Last
Maiden Name of Mother of Deceased
Date of Birth of Deceased Age at Death
Month (. Ie. S'1 J'O
Da Year
/rIlI1 PI Fe-/IJ /V~ I ?J-9<>
Villa e, Town or Cit Coun
, First Middle Last
Place of Death
20 /-Ic.rci.e!j Or
Name of Hos ital or Street Address
Purpose for Which Record is Required
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What was your relationship' to the deceased? 57 II-Tt P () L.J:7:.,E
In what capacity are you acting? (j f r: ~ :r;-/\ VC,Jr
If attorney, name and relationship of your client to deceased
Signature of Applicant 0." ~ /~ Date i< L ~of /
AddressofApplicant's? WA-PPI:'r\.)GeT\. - l8 ,.,..:r:7::J'Q{.(i).sfl 't.J. w"f, N"
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_ Number of copies requested without confidential cause of death
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Name
Address
City
State
Zip Code
DOH-294A (6/2000)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Coe.,v of Death Record
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FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Nam~f Dec?ased
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First Middle
Name of Father of Deceased
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Last
First Middle
Maiden Name of Mother of Deceased
Last
Date of Birth of Deceased
Age at Death
First
Place of Death
Middle
Last
Month
Da
Year
Name of Hos ital or Street Address
Purpose for Which Record is Required
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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 If' 0 rh, / > tI 1~ {/ /('. ~
Date /I~
pr 6s-f'4~ (
I .
_ Number of copies requested with confidential cause 01 death
_ Number of copies requested without confidential cause 01 death
Name
Address
City
State
Zip Code
DOH-294A (6/2000) ~
NOV-5-~~~9 ~9:07A FROM:TOWN CLERK
(845)298-1478
TO: 4547862
P.ut
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Coer of Death Record
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FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Name of Deceased
Annabelle B..
First Middle
Name of Father of Deceased
Kane
Last
Social Security Number of Deceased
First
Middle
Last
Maiden Name of Mother of Deceased
Date of Birth of Deceased
Age at Death
First
Place of Death
Middle
Last
Month
Da
Year
Name of Hos ital or Street Address
Purpose for Which Record is Required
my attorney, John M. Reed
Villa e, Town or Ci Co un
In order to probate the decedent's estate, and assist
in doing so, and then administering the estate.
What was your relationship to the deceased?
In what capacity are you acting?
If attorney, name and relationship of your client to deceased
5~naM.clAppllcant ~~~~. .:;:~~';
Address of Applicant q h k
daughter
proposed Administratrix
Date ii/Ii 09
(
l?fin~
.JUl Number of copies requested with confidential cause of death
_ Number of copies requested without confidential cause of death
Name
Address
City
John M. Reed, Esq.
17 Collegeview Ave.
poughkeepsie,
State
NY
Zip Code 12603
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.
Name of Deceased
f5>'1 IJ E L[/l
First Middle
Name of Fatije of D~eased
!tilT tit< /?-Uf'TS'Cij
First Middle Last
Maiden Name of Mother of Deceased
~ /H /?1 /j Jf?JL ("
First Middle Last
Place of Death
1-/1 j)/p'pZCL /2);;
Name of Has ital or Street Address
Purpose for Which Record is Required
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Date of Death or Period to be Covered by Search
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Last
Social Security Number of Deceased
O~tj- zR"---ZJ9P3
Date of Birth of Deceased Ie:? /
(!!)g--- /9 //~ b
Month Da Year
Age at Death
It) 3'
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Coun
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What was your relationship to the deceased?
In what capacity are you acting?
If attorney, name and relationshi
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)
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
Michael James
First Middle
Name of Father of Deceased
James Michael
First Middle
Maiden Name of Mother of Deceased
Katherine
First Middle
Place of Death
42 Lake Oniad Drive, Wappingers Falls
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
Curry November 14,2009
Last
Basil
Last
Social Security Number of Deceased
083-34-9911 ~~~
,11<.7 ,.Age a
1945 ,..' I I 'hI'''
Year ~
Dut~fBr
Date of Birth of Deceased
5 7
Month Da
Curry
Last
Wappinger
Villa e, Town or Cit
Count
What was your relationship to the deceased?
In what capacity are you acting? Funeral Director
(
Date November 16,2009
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)
~w YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
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FEE: $10.00 per copy or No Record Cef1lIicaliOO. Please do not send cash or stamPS.
Name .~f1 ~ce~Et~.
l} I IA. f.J0 M
First Middle
Name :]f Father of Deceased
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First
Maiden Name of Mother of Deceased
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First Middle
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Last
Month
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Villa e, Town or Ci
Da
Year
Age at Death
.{y
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Coun
Name of Hos ital or Street Address
purpose for Which Record is Required
What was your relationship to the doCO~? =90
In what capacity are you acting? c;J ~
If attorney, name and relationship of your client to deceased
Signa\Ure of Applicant _ =t: "":)....... ~~. J
Addre.. of Applicant ~
Date
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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 Copy of Death Record
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Walter G. Stanjeski
First Middle
Name of Father of Deceased
Last
November 23, 2009
Social Security Number of Deceased
Louis Stanjeski
First Middle Last
Maiden Name of Mother of Deceased
061-22-6325
Date of Birth of Deceased
Age at Death
Helen
Stackowski
Middle
Last
September 12, 1927
82
35 Scribo Lane
Wappinger
Villa e,Town or Cit
Dutchess
Name of Hos ita I 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
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1/ /Z<! (or
,
Name McHoul Funeral Home Inc.
Address 895 Route 82 , P.O. Box A
City Hopewell Junction
State New York
Zip Code 12533
VS-34D
DOH-294-A (7/92)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Death Record
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Name of Deceased
L-e.OI1QYc! che.s.+f.(
First Middle
Name of Father of Deceased
1.j.iAYO IJ
First Middle
Maiden NarTJe of t\1other of Deceased
#lQr.Jor/ e...
First Middle
Place of Death ,
~oUe('c.'t..~ prlVe,
Name of Hos ital or Street Address
Purpose for Which Record is Required
1/; ne..S
Last
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Last
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Last
Date of Birth of Deceased
Fvb 1(,
Month Da
vJq pp; nj ~Y'
Age at Death
S-D
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Coun
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 APpliC~~ EduM4.eL
Address of Applicant
Date If 30 - ~t>()'
~ 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)
~~ZiPCode
NOV 3 0 2009
TOWN CLER~
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Death Record
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Date of Death or eriod 0 be Covered by Search
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First Middle Last Month Da Year
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Name of Has ital or Street Address Villa e, Town or Ci
Purpose for Which Record is R~YJ1 L_
Social Security Number of Deceased
O!5ff- /ft/- 3~ /3
Age at Death
6/
16
Coun
What was your relationship to the deceased?
In what capacity are you acting?
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Signature of Applicant i.
Address of Applicant 3 ~ m /JT,J
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Date /110
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Number of copies requested with confidential cause of death .
_ Number of copies requested without confidential cause of death
((:(:\\...))::PLEAlI:PIINlUJilAMS::ANDAAD. "
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Name
Address
City
State
Zip Code
D~ (6/2000)
/
NEW YORK ST ATE DEPARTMENT Of HEALTH
Vital Records Section
APplication to Local Registrar
for Co of oeath Record
fEE: $;0.00 per copy or No Record certilication. Please do nol send cash or slamps.
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Last
Date 01 Birth 01 Deceased
Age at Death
First
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Middle
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Month
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purpose lor Which Record is Required
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Signature 01 Applicant
Address of Applicant
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_ Number of copies requested without confidential cause of death
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Name
Address
City
State
Zip Code
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital 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.
Name of Deceased
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First Middle
Name of Father of Dece~sed
/1L.bEL1T V .
First Middle Last
Maiden Name of Mother of Deceased . \
3t.AN~ bUS t-(J V\)
First Middle Last
Place of Death
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Date of Death or Period to be COy ~l Search
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Social Security Number of Deceased
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Date of Birth of Deceased
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Month Da
Year
Age at Death
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Name of Hos ital or Street Address
Purpose for Which Record is Required
Villa e. Town or Ci
County
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In what capacity are you acting? 11)Nt&iJU,/) f!a::.rbR-
If attorney. name and relationship of ur client to deceased
Signature of Applicant
Address of Applicant
sJ,gJ GJ!W&Y Ave
HbullbH
Ny
Date 1/;":;3 - D1
1~5'<s~
COMPLETE FOR DEATHS OCCURRING AS OF JANUARY t. 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)
@
~ORK STATE DEPARTMENT OF HEALTH
Vita\ Records Section
APplication to LOCa' Re9lS1.1 ,,"'
for Co of oeath Record
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\1 at\oroe~, name an r ~
Signature 01 ~pp\\Cant
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. ~ner 01 cOllieS re<luoste ..
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~ddress
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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 cash or stamps.
RECEI
NOV 0 ~ 2009
Shirley G. Rumsey
First Middle
Name of Father of Deceased
Last
November 1, 2009
Social Security Number of Deceased
E. Lasell Palmer
First Middle Last
Maiden Name of Mother of Deceased
061-16-1580
Date of Birth of Deceased
Age at Death
Laura
Kratzer
First
Place 0 eath
Elant at Wappingers
Middle
Last
April 16, 1920
89
Name of Hos ital or Street Address
Purpose for Which Record is Required
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 relationship of your client to deceased
Signature of Applicant c1it1A ~ {/Z/YlcL{Y-
Address of Applicant 895 Route 82. P.O. Box A Hopewell
Date
;/ /3)01
Junction. NY 12533
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
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FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. NOV 3 0 2009
N CLERv
Name of Deceased (J
Louw D
First Middle
Name of Father of Deceased
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First Middle
Maid~ Name of Mother of Deceased/ . U / ~ Date of Birth of Deceased 9 Age at Death
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First Middle Last Month Da Year U
Place of Death 1() 2 J~(tl i)3 /I~ Mtf//.1;&zlJ !A//j---
Name of Hos ital or Street Address Villa ,Town or Ci
Purpose for Which Record is Re9uired
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What was your relationship to the ~ased?
In what capacity are you acting? I;J
~ attorney, name and rethiP of your c1ie
Signature of Applicant {,
Address of Applicant
rLJ
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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)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co~y of Death Record
. .. "'PLeAse COMPLETE:FORMANo>eNCLbsE;FES" :</>':,,:: .... ,., ,:.::.
'RECEIVElJ
FEE: $10.00 per copy or No Rectird Certification. Please do not send cash or stamps.
N':' 2 5 2009
T"f)WN CLERV
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First Middle Last
Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death
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Name of Hospital or Str t Address (Village~Town or City County
Purpose for Which Record is Required
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Name
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City
State
Zip Code
nOH-?!=l4A tnr)()()()\
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co of Death Record
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First ~~ lY\~ddle
Maiden N~of Mothe.r of Deceas~
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Signature of Applicant
Address of Applicant
_ Number of copies requested with confidential cause of death
~umber of copies requested without confidential cause of de~th
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Name
Address
City
State
Zip Cod(
DOH-294A (6/2000)
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