2007
~
Application to Local Reg istrar
for COfry of Birth Record
First Middle Last
NEW YORK STATE DEPARTMENT OF HEALTH
\/Ital Records Section
D Passport
~ Social Security-Retirement
~ Social Security-SSI
D Retirement
D Employment
D Other (Specify) (Vlf!> IC.;fj ~;;.
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NAME , ~ If attorney, give name and relationship of your
&u Ire- r::~I/lfJe. /!/II client to person whose record is required
What is your relationship to person whose
record is required?
~ Self 0 Parent 0 Other, specify
Name loul s~ r: 1//11 ;Ve.('
Hospital (If not hospital, give street & number)
Place of ::!J?AG
Birth _ . ~y'P
S p~)j,) b <Sr. MI,RIIt/ ~~ ~
First Middle Last
Father
t/CHAR-A
WGL~Sfl
Number of Copies Requested
I
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Ch~ck One)
Telephone No. (~) ~-ld:l:L2tiJ
Social Security No.lLJ..2:lj-EL@-~
Signature of Applicant
Date
lLlLJ
MM DD
Address of Applicant
r-rJ Y JO u../# ;4 t/g ·
Street
/(,/;1//1 fl/ <fC;;N nu.s MY:
City / State
/ ')~ Jr?)
Zip Code
DOH-296A (11 /94 ) Page 1 of 2
Date of Birth LQLlrJ m I Ilf l-rlll
M M D D~
(Village, Town or City) County
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Middle Last
Maiden Name
of Mother
First
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Enter Local Registration
No. if Known
D Working Papers D
D School Entrance D
D D
D D
Welfare Assistance
Veteran's Benefits
Court Proceeding
Entrance into Armed
Forces
Driver's License
Marriage License
(name of client)
(relationship)
..NEW~YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for COe>' of Birth Record
First Middle Last
[)
Name f\( C
Hospital (If not hospital, give street & number)
Place of ~
Birth Id - .
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First Middle Last
;r-r~/ti5
Enter Birth No.
if Known
Number of Copies R quested
I
Date of Birth 1411 I ~ I fill I I
MM D D TYYY
(Village, Town or City) County
v-t.
Maiden Name First
of Mother LtjfA
Middle
Last
CloRe
Enter Local Registration
No. if Known
D Passport D Working Papers D Welfare Assistance
D Social Security-Retirement D School Entrance D Veteran's Benefits
D Social Security-SSI D Driver's License D Court Proceeding
D Retirement D Marriage License D Entrance into Armed
D Employment ___ z? R _ .. JJ- j) ~ , ~o:es J
D Other (Specify) U( ~ G C!t/0 ~ rr:J...Q l----
Purpose for Which
Record is Required
(Check One)
NAME If attorney, give name and relationship of your
client to person whose record is required
What is your relationship to person whose
record is required?
'0Self D Parent D Other, specify
Telephone No. (~~-~
Social Security NO'h.JhlJLaf~
Date
W1J lL[J
MM DD YY
Address of Applicant .
CjjO YY{/J[(C ns '-jeRir(!e
streegJtLCOl/t. n '~ 1j1~Dg
City State Zip Code
DOH-296A (11/94) Page 1 of 2
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(name of client)
(relationship)
.. N~VYORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for CoPY of Birth Record
First Middle Last
Place of
Birth
I
pital (If not hospital, give street & number)
o
First
Fatheb \
J1~VE~
Middle Last
o Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
o Other (Specify)
NAME If attorney, give name and relationship of your
client to person whose record is required
Number of Copies Requested
,
REC J"I-I J
SEP 1 7 2007
Purpose for Which
Record is m~&JLERK
(Check One)
. (? ~#:l~ L I CY>~
Enter Birth No.
if Known
What iS~ y! r relationship to person whose
record is r quired?
D Self Parent D Other, specify
Telephone No. (~) l2M-~
Social Security No.lillt11J-lfUj-~
:J.-'h ---
Addres of pplicant
<6 d fi'JI..lt: s~
~o -k ivl U
City 1
DOH-296A (11/94) Page 1 of 2
lJy
State
ld.-foD)
Zip Code
Date of Birth LnJ2j ~ llJilrID
MMDDYYYY
(Village, Town or City) County
---:--
J Ow x..1
Maiden Name First
of Mother A J
.~16-s):l.
Middle Last
? f{.-V)J'T00AJ
Enter Local Registration
No. if Known ~ 3
o Welfare Assistance
o Veteran's Benefits
o Court Proceeding
o Entrance into Armed
Forces
iWOrking Papers
School Entrance
Driver's License
o Marriage License
1-
(name of client)
(relationship)
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for CoPY of Birth Record
First Middle Last
Date of Birth fu Ll1J ~
MMDDYYYY
(Village, Town or City) County
Name C.
Hospital (If not hospital, give street
Place of
Birth
o Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
o Other (Specify) !v 0 ~ S
NAME t1 L If attorney, give name and relationship of your
\.r cJ \ ~ client to person whose record is required
What is your relationship to person whose
record is required?
~elf 0 Parent 0 Other, specify
Telephone No. (~) ~~
Social Security No.lLkW-.gJfd-~
First
Middle
Father
CI+
/~
L
Number of Copies Requested
Purpose for Which
Record is Required
(Check One)
Last
DC{ reA ess
Middle Last
G. C-12-1- ~S
Maiden Name
of Mother
First
yY) r+ Il. 't
IJ l S" 0 h...
Enter Birth No.
if Known
Enter Local Registration
No. if Known
0 Working Papers 0 Welfare Assistance
0 School Entrance 0 Veteran's Benefits
0 Driver's License 0 Court Proceeding
0 Marriage License 0 Entrance into Armed
Forces
L
(name of client)
(relationship)
Date
lQl1J lLl2J 0 .
MM DD YY
Address of A plicant
q~(g ROlJ~~~f?-Qr
Street
City
State
0"'-
DOH-296A (11 /94 ) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for CoPY of Birth Record
First Middle Last MAR 2 8 2007
Date of Birth lJUJJ I olll1;? I 0 I ~ 51
Name 1 a ithe ' Yv'lO S' c ~ M M [)1p"'fNQt&RJ(
Hospital (If not hospital, give street & number) (Village, Town or City) County
Place of
Birth (')0 0 ld Pos -+ '{2d. (}JuffS Cd ((s
~"")A ~" / ) \-~O
---.. '
Dufcw'SS
Father
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.A VVta SC h
Maiden Name First Middle Last
of Mother 1-e(/l v\ \ +e r L, t-{ c\(l c\ ,
First
Middle Last
1.
Enter Birth No.
if Known
Enter Local Registration
No. if Known
Number of Copies Requested
o Passport 0 Working Papers 0 Welfare Assistance
o Social Security-Retirement 0 School Entrance 0 Veteran's Benefits
o Social Security-SSI 0 Driver's License 0 Court Proceeding
o Retirement 0 Marriage License 0 Entrance into Armed
o Employment Forces
~ Other (Specify) ~ If () Y/ f1 \ of (d () (/ '-.{ 0a. V e.. a c O( 1) .
NAME "t 0 r'. L ;} (If attorney, give name and relationship of your
J # U r:. ,. (( )c1ient to person whose record is required
What is your relationship to person whose
record is required?
0Se1f [ffParent 0 Other, specify
Purpose for Which
Record is Required
(Check One)
1-
Telephone No. (WLW) ~-~
Social Security No. LLl{1{j-L12J-~
(name of client)
(relationship)
/
\,
,
Of Applicant
2 "1 d- h Sh kr 1/ Q (/'<
Street. -11 tJ
Ci~~ U1/l State.J
/Jr-o~ .
Signature of Applicant
,.---.... .
Date
~~o
MM DO YY
Zip Code
DOH-296A (11 /94 ) Page 1 of 2
.....~
NEW YORK STATE DEPARTMENT OF H~ ~~ication to Local Registrar
Vital Records SectionJ/ (1l4? ii(,JJY il FEB 2 1 2ooT~ for Co~X of Birth Record
First
Middle
Last
?~ (t',J
Name
~o ,/
Hospital (If not hospital, give street & number)
Place of
Birth
First Middle
Father Sr z. V [..,,)
Last
'"i2~~(DN
Number of Copies Requested
Enter Birth No.
if Known
Date of Birth L1iJ ~ ~
MM DDYYYY
(Village, Town or City) County
\J
Maiden Name First
of Mother C L.I
-It '( D Y 'IJ
c-A~58
Middle Last
9!~ 1 ( " J
.J"S
Enter Local Registration
No. if Known
D Working Papers D Welfare Assistance
D School Entrance D Veteran's Benefits
D Driver's License D Court Proceeding
D Retirement D Marriage License D Entrance into Armed
D Forces
Employment ()
D Other (Specify) _(f ~ I
NAME If attorney, give name and relationship of your
client to person whose record is required
D Passport
D Social Security-Retirement
D Social Security-SSI
Purpose for Which
Record is Required
(Check One)
What is your relationship to person whose
record is required?
~elf 0 Parent 0 Other, specify
Telephone No. (lZJ.ill) lflfliJ-~
Social Security No.UltJ-~-~
Date
~~/!)1
MM DO YY
:2 1 f 0 U 1/11 P t1J ;-f I ~ t- r< j)
Street
City C ~ State It L Zip Code
35"1 ?s-
DOH-296A (11/94) Page 1 of 2
(name of client)
(relationship)
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