Box 178
Records Inventory Data Worksheet
Print Form. J
See Instructions in Publication #76, "Inventory and Planning", Before Completing Form
Government Agency h<.l"-...IA ~\ yJ hP~\{\~t( ... Department I. \\ ~9\; ";'\<!\~.
Record Series Title I'" ~ X'.
.. \\ -IY\( ...... b.~:{ OS
I Date Span
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Records Series
Description
\'''^'''t S ~(t ~~ -~\j \jC\
~~
....---------
(describe content
and characteristics
of records)
. ...... .
. .
.
r Alphabetical
r Numerical
Arrangement 6) Chronological
r Alphanumeric
r Other (specify) I
C Not Scheduled Retention per;Odl~~~\~b~~\ ~
~ ~ e, ~ I '')
r Permanent
Retention m .... ..
C Historic
<I Scheduled Schedule # 1..5m,r~'j~\J .m-II Schedule I h-'}g L\ ., I
I - ....
Location
Format . Paper r Audio-visual CMicrographic r Electronic
Total Quantity r Cubic Feet: r Items Amount: I Type of Items: I
Annual rCubic Feet Amount: I I Items I
Accumulation ...
Frequency of Use rDaily r Weekly CMonthly _Seldom r. Never I
Restrictions on Use IN/A
..
Records Are: In Poor r Vital (Essential _Official Copies
r Condition to Operations)
Name of Person Completing Record I \\ {, ",', '/'Il.. lJh.J~ ;1 Date I ~ -~,.\\ I
~
New York State ArchIVes
JCM (2011-01-05)
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