Interlineation Example
'j
DOH-1961 (0512003)
RESIDENCE
NCHS
4C
46
RECORDED DISTRICT
.~ · NEWYORK~ATE
~1~~R~;;~~O(;~L~EATH
MIDDLE LAST
S"WlI+L
PRIVATE HOSPICE OTHER
RESIDENCE FACILITY (Specify):
ODD
I 40. LOCALI1Y: (ChtICk on, and spscify)
I CITY VilLAGE TOWN
10 0 0
t 4G. WAS DECEDENT TRANSfERRED FROM ANOTHER INSTITUTION? (If yes. specify institution name, city or'
I NO YES
I 0 0
. 6A. AGE IN I 68. IF UNDER 1 YEAR I &C. IF UNDER 1 DAY t 7A. CITY AND STATE OF BIRT
YEARS: I ENTER: ENTER: I RegionlProvlnce)
t months dIys: hours. minutes I
{f I : I I
yrs. I I I ,
9. DECEDENT OF HISPANIC ORIGIN? Ch<<:t 11II bo1tIII Mut bISt dIscttbI whIIhtr thI dIcIdItrt is ~ 10. DECEDENT~
A 0 No. not SDanishlHimaniotatinD B 0 Vel.. Mmr.an. ftleran Anwir.:m. r.hlr.M"
REGISTER NUMBER
2. SEX:
MAlE
01
1. N. AME: ARsr....;- . S
~ VA,.-te..
4A. PlACE OF DEATH: HOSPITAL HOSPITAL HOSPITAl
(Check one) DCA ER OUTPATIENT INPATIENT
o 0 0 0
4C. NAME OF FACilITY: (If not facility, give address)
NURSING
HOME
o
4f. MEDICAL RECORD NO.
5. DAlE OF BIRTH:
MONTH DAY
. ,....,..~ h ._
8. SERVED IN U.S. ARMED
FORCES? (SpIdfy ,.,IS)
(Qr€a
NEW YORK STATE DEPARTMENT OF HEALTH Application for Correction
Vital Records Section of Certificate of Death
See Reverse Side for Instructions
Deceased r:f':4,.,.€ S ~~ ./-1, District Number
Date of Death Register Number
Place of Death State Number
I,
;/bs-e;o1.. G~
(name of applicant)
of
~yt ~c1 tJltrk ~fI,
(address of applicant)
request that the following information amend the certificate of death identified above:
AS IT APPEARS
AS IT SHOULD BE
Documentary evidence submiUed herewith in support of this application includes:
Explain reason lor error or omission: 7Yl a ef t:. 6-y ~'to.(J Dt/z e ~
/?jfM
The above information has been added to the local record of death on file in this office.
101M S/~I1~ kC4L &mt~;t;f)
SignalUre 01 Registrar District Number
Date
DOH-299 (6/99) Page 1 of 2
(OVER)
. \L' ~ . NEW YORK STATE
T ~ CER~~;~";.~O~~L~EATH
~ E1l4!2ii ~
'. (Check one) DOA ER OlJTPATIENT INPATIENT - "'~ RES'IDENCE
000 ~ 0 0
STATE FILE NUMBER
1,:,1- 200 5-0()OOO If
-
t
2. SEX:
MALE
01
~'
----.nn""""-
FACILITY (Specify):
o 0
FEMALE
X~2
3A. DATE OF DEAllI:
MONTH DAY
01
I 38. .HOUR:
m
4C. NAME OF FACILITY: (If not facility. give address)
I 40. LOCAliTY: (Check one and specify) C l." t Y
I CITY VILLAGE, TOWN
Wilson Memorial Hospital I 0 ~ OVilla e of Johnson
.~ ".~".^.. ....M.". "^ , 46. W~ DECEDENT TRANSfERRED FROM ANOTHER INSTITUTION? (If yes, specify institution name, city or town, county and state)
~ m " "
o ~ Ell.zabeth Church Manor, Bl.nghamton Broome NY
6A eg~J~. I 68. ~tJ~~g.ER1YEAR I BC. ~N~g.ER1DAY I 7A. ~'!!.~~'}g~:'~~~IOFBIRTH:(JfnotUSA.Coun/ryand I 78. ~g.UNDER1YEAR.NAMEOFHOSPITALOF
YEAR
2004
5:UA'ffOFBIRTr1;
(
"--~
~
,
Wi't-L,*WI JII?/~'" . A-rr(.AIQ~~, P.J,'I,,(;C/~
26B. Deceased la~ seen alive MUIIDI
" , by attending physician: I
PENDING 28. WAS~SE RE RRED TO
HOMICIDE SUICIDE INVESTIGATION CORONER MEDICAL EXAMINER?
03 04 06 0 0 1 DYES
CONFIDENTIAL SEE IISTRUcnON SHEET FOR COMPLETING CAUSE OF DEA
30. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR (A), (B), AND (C).)
PART I. IMMEDIATE CAUSE:
(A)
DUE TO OR AS A CONSE~UENCE OF:
. (B) .-
a DUE TO OR AS A CONSEQUENCE OF:
. (C) ,.
PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO
OEAllI BUT NOT RELATED TO CAUSE GIVEN IN PART I (A):
. 31A. IF INJURY, DATE:
MONTH DAY YEAR
J .-_.-. I
,-
-j
M
APPROXIMATE INTERVAl.
B8WHN ONSET AND DEATH
~
1 n PrM~nt ,,' tilT\ll nl rl"i1'h
DID TOBACCO USE CONTRIBUTE TO DEATH?
o 0 NO 1 0 YES 2 0 PROBABLY 3 0 UNKNOWN
I 310. PLACE OF INJURY: I 31E.INJURY AT WORK?
I INO YES
I 100 01
33B. DATE OF DElIVERY:
? n Nrit ..""..., ... ~"'n'..;'.;n" d_ .f...... MONTH DAY
I 318. INJURY LOCALITY: (City or town and county and state)
I
, m i
32. WAS DECEDENT 33A. IF FEMALE:
~!'!!~~l~.!l.~~ NO YES 0 n Not oreonant wiIIin last VAA<
I 31 C. DESCRIBE HOW INJURY OCCURRED:
I
I
YEAR
Medical/B
[~ r
STATE OF NEW YORK
DEPARTMENT OF HEALTH
VITAL RECORDS SECTION
DISTRICT # O-i...03
REGISTER # 5
STATE FILE # 00 ,/~,fl
Name of Deceased
Medical/Burial Death Correction Report
Date of Death Place of Death
lfLl
~y YEAR
2OC. LoeA T10N; (City a town snd state)
II
CONFIDENTIAL
APPROl(IWlTII
BE1WWfONSET AND DEA lM
~. and"""'! 31C.OESCRlBEHO'NINJURYOCCU, D:
[0~ I "
~! l
33A. IF FE
OONd_t;: 'OP_""'''- 20NdJ><8ll. t", ..wi....,..)'..''''''
" . ~
'00'""_ D. 0' 3DNd_bojI, 43dll)'llo'jIlOfbefoq"'~ 40U_'''"9- I!r )'I"
Affirmation to be completed by Funeral Director (Item ?~.24B) or Certifying PhYSICia~(ltem 25A-33B):
I affirm under penalties for perjury that the information given i~ fac:Q of the certificate of death for the deceased person identified
above is true and correct information to be added 10 the original certifica death and the local registrar's record.
\:;'
i
OlD TOBACCO USE CONTRIBUTE TO OEATH1
00 NO 1 0 YES 2 0 ~ROlWIl y sO l1N<hOWN
F INJURY : )lE NIUR'Y ATWMa
. lC) YES
D. D.
VEAR
\~.!!
....j
11
U
To be completed by registrar of vital statistics:
The above information has been added to the local record of death on file in this office.
W'i~&Y"""
.ml W "'.-"Y".
District Number
Dale
DOH-1999M (02/2003)
.~~. .
. ...U"\n',~
. ...._............."'T..
2.-SEX:
MAlE
01
4C. NAME OF FACILITY: (If not facility, give address)
G4MpL€-
- '. tc:neCKOner'-- -OOA--Nf- -. Otm'ATIt:Nr-'AfI1\ nmr- ''"'"''froME--' --m:l:iTlJENt.T~~l"AClLlrr~ecll'Yj.
o 0 0 III 0 0 0 0
I 40. LOCAlITY: (Check one and specify)
I CITY VILLAGE TOWN
Medical Center Hos ital I fXI 0 0
. 4G. WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION? (II yes, specify institution name, city 0
I NO YES
2
Alban
4F l4EDICAL RECORD NO.
'I
1
:z.'SA.
ztil'- AtterKll!::I~ 4S M ,-::01.)' s. e OIL-. AJ "
attended deceas~d: FROM
27. MANNER OI'DEATH:
NATURAL CAUSE. ACCI
01
~ \
.....
(\ I "2-~.l1
:i::
55
o
30. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR (A). (BJ. AND (C).) .
PART I_ IMMEOW CAUSE:
(A) ~
DUE TO OR AS A CONSEQUENC OF:
(B) ..
DUE TO .OR AS A CONSEQUENCE OF:
(C]
.. PART II. OTHE:'. SIGNIFICANT CONDITIONS CONTRIBUTING TO
DEATH BUT NOT RELATED TO CAUSE GNEN IN PART I (A):
,I
~J
APPROXIMATE INTERVAL
8ElWEEN ONSET ANO OEAlli
vI",. L-
~
jl
~lA IF IMIIIRV nATF.
~nllll'
')10 '"llltnV t n"''''IIT'\/. I"'~... __&_
DID TOBACCO USE CONTRIBUTE TO DEATH?
o "NO 1 0 YES 2 0 PR08ABl Y 3 0 UNKNOWN
o
6"-
4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
VITAL RECORDS SECTION
Medical/Burial Death Correction Report
Date of Death Place of Death
Name of Deceased
GX.AoNt7Lcc:...
2-
2OC.LOCATION; (CitycrtcJwntlfld.tfQj
2.18. REGISTRAnON NUMBER:
22C. REGISTRATION NUMBER:
CONFIDENTiAL
.""'...","""'"
~CHlE'TIJClDEA1H
',~""
ftJ=* 20,.....
400n0.....
Affirmation to be completed by Funeral Director (Item 248) or Certifying Physician (Item 25A-338):
I affirm under penalties for perjury that the information given in e facs@nW of the certificate of death fOf the deceased person identified
above is true and correct informa~on to be added to the original cerlifica~ d;ath and the local ragislra(s racord.
To be completed y registrar of vital statistics:
Tha above information has been added to tha local record of death on fila in this office.
....'''".- .
1""""" SOM"'"
~w. ~'bM--/;;L Lne4L ~ck&
10I''''IN=...
I o,~
DOH-199iM (0212003)
"'"
....