2007
,-,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section, Genealogy Unit
P.O. Box 2602
Albany, New York 12220-2602
'"
General Information and Application
For Genealogical Services
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
1. FEE - $22.00 includes search and uncertified copy or notification of no record.
2. Original records of births and marriages for the entire state begin with 1881, deaths begin with 1880, EXCEPT for records filed in
Albany, Buffalo and Yonkers prior to 1914. Applications for these cities should be made directly to the local office.
3. The New York State Department of Health does not have New York City records except for births occurring in Queens and
Richmond counties for the years 1881 through 1897.
4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical
research.
To insure a complete search provide as much information as possible
, requested-~,
Please complete for type of record death OR marriage.
..-..... Name at Birth 1- D rtlJ!. 7$ ~N1l-tJ__ Name at Birth
Date of Birth ~ v 7 I ~'i z..- Date of Birth
........ :::::::::::::::::
"I" Place of Birth Wlr--fPOJc3iEtL Ft-U6 IVV "I, Place of Birth
:::.::: / :::1:::
Father's Name f~+F.6(L f f3(LfUI V~ N ;:;:::::::::::::: Father's Name
ijjjjj~II~;
.;.:.:.:.;.;.:.:. Mother's Maiden Name r1 ft-" Y J f' Mother's Maiden Name
, I
:::::;:;:::;:::::
;.:.:.;.:.;.;.;.; Name of Bride :::::I::~ Name of Bride
:m:I:::
{:~ Name of Groom ':::. Name of Groom
"I" I"
:::::lI;i;i;;:::
{:D:~: Date of Marriage .1111. Date of Marriage
"ti" Place of Marriage Place of Marriage
fIfj} and/or Ucense .::::::::::::::;' and/or Ucense
:::::::::::::::::
.................
................
Name at Death Name at Death
Date of Death Age at Death I Date of Death Age at Death
"1"
........
{: ...m Place Place
:::::.::: of Death of Death
:~:Ct Names of Parents Names of Parents
:~:~:r~:~:j:~:
Name of Spouse Name of Spouse
::;:::::::::;::::
.;.;.;.;.:.:.:.:
For what purpose is information required? ~ In. '7-- ~ e Ell- f I F ~ c-A f~
What is your relationship to person whose record is requested? ti ~!Jj S; ~ J.J
In what capacity are you acting?
SIGNATURE OF APPUCANT ~ ~c ~ ..
ADDRESS tl f ,v; , IT -'-A&
DATE 1- 29 -,7
J.J...v L/-z,/~
Name 3~'A/~Ltf '1(2~ql2-L;t/
Address :3 d f ~!,.l.L; ~ ~tJ nL
City l]tI~ State Ai' Zip Code !YLJp
If requesting birth and marriage records, please sign the following
statement:
To the best of my knowledge, the person(s) named in the application
are deceased.
SIGNATURE OF APPLICANT
DOH-1562 (06/2003)
~()~ /1 . LUle.; C7----rL
.~, CL tId 1. j C.
(over)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section, Genealogy Unit
General Information and Application for Genealogical Services
VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES.
Return to: New York State Department of Health, Vital Records Section, P.O. Box 2602, Albany, NY 12220-2602
1. FEE - $22.00 includes search and uncertified copy or notification of no record.
2, Original records of births and marriages for the entire state begin with 1881, deaths begin with 1880, EXCEPT for records filed in Albany,
Buffalo and Yonkers prior to 1914. Applications for these cities should be made directly to the local office.
3. The New York State Department of Health does not have New York City records except for births occurring in Queens and Richmond
counties for the years 1881 through 1897.
4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical research.
To insure a complete search, provide as much information as possible.
Please complete the applicable section for each type of record requested: birth, death or marriage.
Name at Birth William Myers (great grandfather) Name at Birth William Myers (grandfather)
1871 State File 1898 State File
.c Date of Birth Number .c Date of Birth Number
't Place of Birth New York 't Place of Birth Wappinger Falls, Ny
I- I-
m Father's Name possibly John Myers (great-great grandfather) m Father's Name William Myers
Mother's Maiden Name possibly Cornelia (unknown last name) Mother's Maiden Name Katie (unknown last name)
CU Name of Bride Katie (great grandmother-unknown last name) 8 Name of Bride Margaret Curry (grandmother)
m
ftI Name of Groom William Myers (great grandfather) ftI Name of Groom William Myers (grandfather)
I- I-
I. State File I. Slale File
I. 1894 I. 1916-1920
ftI Date of Marriage Number ftI Date of Marriage Number
% Place of,Marriage New York % Place of, Marriage New York
and/or License and/or Ucense
Name at Death William Myers (great grandfather) Name at Death William Myers (grandfather)
Date of Death unknown Age at Death unknown Date of Death unknown Age at Death unknown
.c .c
.. Place of Death Wappinger Falls, NY .. Place of Death Wappinger Falls. NY
ftI ftI
CU Names of Parents possibly John and Cornelia Myers CU Names of Parents William Myers (great grandfather)
Q Q
Name of Spouse Kathrine (unknown last name) Name of Spouse Katie or Katherine (possibly remarried)
State File Number State File Number
For what purpose is information required? Genealogy research
What is your relationship to person whose record is requested? My great grandfather and my grandfather
In what capacity are you acting? Trace my heritage
SIGNATURE OF APPLICANT
Address
Send record to: (please print)
Name Virginia A, Stout
DATE
Phone (352) 728-6054
If requesting birth and marriage records, please sign the following
statement:
To the best of my knowledge, the person(s) named in the application
are deceased.
Address 22228 Oxford Heights Drive
Leesburg
State FL Zip Code 34748
City
SIGNATURE OF APPLICANT
DOH-4384 (12/05) Page 2 of 2