2005
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Application to Local Regfgtrar
for CoPY of Birth Record
First Middle Last
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MMDDYYYY
(Village, Town or City) County
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Name /flit/< Y
Hospital (If not hospital, give street & number)
Place of
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Number of Copies Requested
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(name of client)
(relationship)
NEy.l YO~K STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Birth Record
First
Middle
Last
Name I-I~^,.;e. ;:- /5u.ch 4~
Hospital (If not hospital, give street & number)
Place of
Birth I
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Middle
Last
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(Village, Town or City) County
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Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
Enter Local Registration
No. if Known
D Working Papers 0
o School Entrance 0
o Driver's License 0
o Marriage License 0
Welfare Assistance
Veteran's Benefits
Court Proceeding
Entrance into Armed
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Social Security No. LW-W-~
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Date
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MM DD YY
Signature of ~~
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Address of Applicant
Street
City
State
Zip Code
DOH-296A (11/94) Page 1 of 2
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client to person whose rec.Qrd i required
(name of client)
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
D Passport
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'NA~A'E'i:;./)u'JQ~ t) ze-II.J-vI If attorney, give name and relationship of your
client to person whose record is required
Hospital (If not hospital, give street & number)
Place of
Birth
First
Middle
Last
Father
Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
What is your relationship to person whose
reco;d is required?
f!f Self 0 Parent 0 Other, specify
Telephone No. (~) ~-~
Social Security No. ~-~-~
Date
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MM DD YY
Address of Applicant
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DOH-296A (11 /94 ) Page 1 of 2
Date of Birth lQJZJ LOO ~
MMDDYYYY
(Village, Town or City) County
Maiden Name
of Mother
First
Middle
Last
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No. if Known
D Working Papers D
D School Entrance D
D D
D D
Welfare Assistance
Veteran's Benefits
Driver's License
Court Proceeding
Entrance into Armed
Forces
Marriage License
(name of client)
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Application to Local Registrar
for Co~y of Birth Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
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, Maiden Name . I
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, D Social Security-Retirement Veteran's Benefits
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i Purpose for Which D Social Security-SSI Court Proceeding I
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(Check One) F
D Employment orces
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D Working Papers D
D School Entrance D
D Driver's License D
D Marriage License D
What is your relationship to person whose
record is required?
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(name of client)
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(relationship)
Telephone No. (~) ~-LLW
Social Security No. Ll1J-W-WlJ
FOR REGISTRAR'S USE ONLY
(Photocopy tD and attach to apphcalton form)
Signature of Applicant
Date
WW
MM DD YY
TYPE OF 10
Driver's License
State _ No.
Address of Applicant
D Other 10, specify
Street
No.
City
State
Zip Code
DOH-296A (11/94) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe)' of Birth Record
First
Middle
Last
Name ~~l[LT ;:J ,
6Wr!ber=r-c
Hospital (If not hospital, give street & number)
Place of
Birth {g {-{ (&-b-f- ST
Date of Birth lQW ~ ~
MM DDYYYY
(Village, Town or City) County
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First
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Middle Last Maiden Name First
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Middle Last
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If attorney, give name and relation hip your
client to person whose recor-d is re ire
Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
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NAME
What is your relationship to person whose
record is required?
o Self 0 Parent 0 Other, specify
Telephone No. (LW) LW-~
Social Security No. UlJ-W-LLW
Signature of Applicant
Date
WW
MM DD YY
Address of Applicant
Street
City
State
Zip Code
DOH-296A (11/94 ) Page 1 of 2
Enter Local Registration
No. if Known
D Working Papers D Welfare Assistance
D School Entrance 0 Veteran's Benefits
D Driver's License D Court Proceeding
D Marriage License D Entrance into Armed
Forces
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(name of client)
Application to Local Registrar
for Co~ of Birth Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Date of Birth lQLkj ~ ~
MM DDYYYY
(Village, Town or City) County
First
Middle
Last
Maiden Name
of Mother
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Mi Ie Last
Father
Enter Local Registrati n
No. if Known
Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
D Passport
D Social Security-Retirement
Q Social Security-SSI
D Retirement
o Employment
[Xl. Other (Specify)
D Working Papers D
o School Entrance D
D Driver's License D
D Marriage License D
Welfare Assistance
Veteran's Benefits
Court proce~i g
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Forces S
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What is your relationship to person whose
record is required?
o Self 0 Parent 0 Other, specify
Telephone No. (LllJ) LllJ-UW
Social Security No. LllJ-W-UW
(name of client)
(relationship)
form)
Signature of Applicant
Date
W lLJ]j 0
MM DO YY
Address of Applicant
Street
City
State
Zip Code
DOH-296A (11/94 ) Page 1 of 2
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JOHN S DYSON
JOLlNE E DYSON
12 LINDA COURT
P.O. BOX 539
SCHROON LAKE, NY 12870-0539
2156
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55-7265/212
Paytothe~ ~.~ cr ~ ff: ~..~~
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SMITH BARNEY
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D 800-232-4454
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TOWN OF WAPPINGER
TOWN CLERK
SUPERVISOR
JOSEPH RUGGIERO
GLORIA J. MORSE
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TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
The Following Fax Message Consists of '- :J pages
Including Cover Sheet
FAX TELEPHONE NUMBER (845) 298-1478
DATE ~ /7 ~/}~.5
/
1/ "'/
TO ~/~ t: .
FROM ?~_ (!k..lf.J ~-
REFERENCE
/n/lTTHE~ 0I'18,fIEL..
IF YOU DO NOT RECEIVE ALL THE PAGES, PLEASE
CONTACT SENDER IMMEDIA TEL Y.
Sender:d~L.c- -fl7 1(J~~'~
COAlF/iJE/VTA-L
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."~~.,.. ....~~_......,"-..-
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TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS. NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
March 17, 2005
Attention: "Insurance Company"
Member's Name: Timothy B. Pinczes
Soc. Sec. #: 086-569-024
Attached is a copy of the birth certificate for Matthew Gabriel Pinczes,
infant son of Timothy B. Pinczes and Jennifer Linda Pinczes.
A copy of the birth certificate is being sent to you per request from the
mother, Jennifer Pinczes so that the infant can receive benefits.
c;d~~~
Sandra Kosakowski
Deputy Town Clerk
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI