2006
Recorded District
New York State Department of Health
Register Number
CERTIFICATE OF
LIVE BIRTH
State File Number:
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lA. Nam First
S~
lB. Medical Record No.:
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3. Sex:
-E.-
5. Place of Birth: 0 Hospital 0 Freest
o Clinic/Doctor's Office
6A. Facility Name:
o Home Delivery: Planned to deliver at home? 0 Yes 0 No
6C. County of Birth:
7A-l. Name: First
Middle
7A-2. Maiden Last Name:
7B. Date of Birth:
Current Last Name
PI
(Country, ifnotUS.A.)
Ill:: 8A. Residence, State: (Country, if not Us.A.)
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6 8C. Locality:
:E
8B. County: (Terr. or Prov., if not USA)
80. If City or Village, Is Residence within City or Village Limits?
(If NO, specify town:)
8E. Street and Number of Residence:
8G. Mailing Address:
8H. Zip Code:
8F. Zip Code:
Ill:: 9A. Name: First Middle Last
W
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I- 9B. Date of Birth: /9C. City & State of Birth: (Country, if not Us.A.)
CC
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lOA. I certify that the stated information concerning this child is true to the best of my knowledge and belief.
I- Signature ~
Z 10C. Name of Certifier, If Not Attendant: Title:
CC
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ffi 10E. Attendant's Name: Title:
J:
CC llA. Registrar Name:
Year
10F-l. NYS License Number:
(Attendant}
12. Information Added or Corrected:
Item No. Date of Correction
oJC
Authorization
Or/ginallnformation
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First of all, I need to know your father's name to check our village records to see if the
birth is listed in the record book. If he already sent his request to Albany, there is nothing
we can do to stop the Albany request. However, if he has not sent the request to Albany,
(and if we have the record here) he can request the certified copy from our office at a $10
fee. The request cannot be done via e-mail. If you give me his name and address, I can
send him the form or you can go online and get a copy of the form - NYS Dept. of Health _
Vital Records Section. The form must accompany one of the acceptable identifications
listed on the back of the form. Your father must sign his form in front of a notary and the
notary's stamp must appear on the form.
Send completed form, along with a check in the amount of $10 made payable to "Town of
Wappinger" and his identification to: Town Clerk, Town of Wappinger,
20 Middlebush Road, Wappingers Falls, NY 12590. The name of the form is-
"Application to Local Registrar for Copy of Birth Record"
-----Original Message-----
From: Monica Hollis [mailto:msalmonhollis@bak.rr.com]
Sent: Thursday, September 07, 20063:38 PM
To: Sandy Kosakowski
Subject: Re: Certified Birth Certificate
My fatherl was born 4/24/1926 in the Village of Wappingers Falls, NY. He filled the
application to send to Albany, could he mail that directly to your office with the $10..00
payment and save himself $20.00?
Thank you,
Monica Hollis
----- Original Message -----
From: Sandy Kosakowski
To: msalmonhollis@bak.rr.com
Sent: Thursday, September 07,2006 12:21 PM
Subject: Certified Birth Certificate
In answer to your fax to the Town Clerk, Chris Masterson:
A certified copy of a birth certificate may be obtained from the town/city in which
a person was born (if a home birth). If a hospital birth, the birth certificate can be
obtained from the Registrar of that particular hospital.
The fee through a town clerk is $10. Albany fee is $30.
Find out the exact location and date of your father's birth. If it was a home birth in
the Town of Wappinger or the Village of Wappingers Falls, please contact us
again.
We will then send you the form to fill out to obtain a certified copy through our
office.
Sandra Kosakowski
Deputy Registrar of Vital Statistics
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registr,-,"I
for Copy of Birth Record
First Middle Last
Name
Date of Birth lQJ1J lQJfj ~
MM DDYYYY
(Village, Town or City) County
Waff/~t& f;f{s u~
Hospital (If not hospital, giv
Place of
Birth /S() {u/c/mer Rcl.
First
Middle
Last
Maiden Name First Middle Last
of Mother YaSM/j1-.Q ()a he C2hmeJ
Father
Chrislofiar John Jhi!!J4
Number of Copies Requested
I
Enter Birth No.
if Known
Enter Local Registration
No. if Known
D Passport
D Social Security-Retirement
D Social Security-SSI
D Retirement
D Employment
D Other (Specify) .SDC S~c :tt
..
NAME , If attorney, give name and relationship of your
' 1M, J'j1t
'" client to person whose record is required
What is your relationship to person whose
record is required?
o Self ~arent 0 Other, specify
Purpose for Which
Record is Required
(Check One)
D Working Papers
D School Entrance
D
D
Driver's License
D Welfare Assistance
D
D
D
Veteran's Benefits
Court Proceeding
Marriage License
Entrance into Armed
Forces
Telephone No. ([Ll~) ~-L1lLltlZJ
Social Security No.lQlzjJ-l2lf:J-l(kJQlfJ
(name of client)
(relationship)
SiWjl ,ture of Applicant
<' ' I
/ ,).;/~
Cidress of Applicant
It () WI (f YVlf( IZd-
Street r- / / M ' 1 rQ()
/JJQ Pf}J{lfftS. j,o((S ~ loW-I
City f f State Zip Code
Date
WW
MM DD YY
DOH-296A (11/94) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for COe>' of Birth Record
First Middle Last
Name ~aJ~
Hospital (If not hospital, give street &
Place of /J - .1J ,_ /JI/ '
Birth 31 uaU JI1w.. tbJfJ
First ,
Father mWl/a
Middle
'J/lqA
Last
VuY~
Number of Copies Requested
I
D Passport
D Social Security-Retirement
D Social Security-SSI
D Retirement
D Employment
D Other (Specify) . "tV
1:/I:IIIIIIII/I//lil///IIIIIII:illllll/illlllllll:llll11/!/I/II/I!//I/IIIIII//I/lillilllll:::I:II:I/I//11111ill/:/II/IIII/I/II/:I/I/I/IIII/////II/II/!!II/II/IIIIIIIlllli:i,I_."
NAiijfE'...... , ~,' , If attorney, g, ive name ~',~ rel~tionship of your
Il(;'" client to pe):,son wh9ge recor9 IS required
What is your relationship to erson whose , ~ l..' (, /
record is required? I 1 ~ \, I
D Se~ ~arent D Other, specify .'~ -'I 1L', l I
10 H if I 1'"'\ II I1II 15V11 VI 'II (name of client) (relationship)
Telephone No. (l.QJ::tJ,}J) ~-LLt1LQLlJ
Social Security No.filJl1J-~-l1llW
Purpose for Which
Record is Required
(Check One)
Enter Birth No.
if Known
Date
lQlhH2EJ 0
MM DD YY
1J.00 )
Zip Code
DOH-296A (11/94 ) Page 1 of 2
mber)
Date of Birth LLQJ l!JQj ~
MM DDYYYY
(Village, Town or City) County
LJt2fJj/~~pft~ ~~
Maiden Name i lirst
of Mother ifJ./flti..-
Middle Last .
IJ-t~ J1td~
Enter Local Registration
No. if Known
D Working Papers D
D School Entrance D
~4ver's License D
D
Welfare Assistance
Veteran's Benefits
Court Proceeding
D Marriage License
Entrance into Armed
Forces
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 ervices
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.
Please complete for type of record requested, birth, death OR marriage.
Name at Birth
Name at Birth a
:{,:;;,: Date of Birth I.. (k)r1. ~~ I I q I a
. Place of Birth /ilwJ1tfl€rS 1cd!, !:LV
11III1 Fathers Name ~.~e H-/+ f
:.....::.. Mothers Maiden Name 0 )N e i (
........
Date of Birth
1:11111
Place of Birth
Father's Name
Mothers Maiden Name
i
Name of Bride
Name of Bride
::!If:
IIII
:,:,:lI;j;j;j:::
:::::1""
E'
Name of Groom
::!If'
::;;;~
'I'
:,:;:lI;j;j;j:;:
"4',,,
'E'
Name of Groom
Date of Marriage
Place of Marriage
and/or License
Date of Marriage
Place of Marriage
and/or License
Name at Death
Name at Death
Date of Death
Age at Death
Date of Death
Age at Death
'i'
i::::I:::
,:Q:"
Place of Death
'C'
:::::1:::
:,:I!t:
Place of Death
Names of Parents
Names of Parents
Name of Spouse
Name of Spouse
For what purpose is information required? .uedl CO("cJ
What is your relationship to person hose record is requested? 'J)QUf! /;rI(:>rr
In what capacity are you acting?
SIGNATURE OF APPLICANT
ADDRESS
Send record to: (please print)
DATE ~5- 1'7- 0 to
Name
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
City
DOH-1562 (06/2003)
State
Zip Code
SIGNATURE OF APPLICANT
(over)
IVED~ .f;)~-cn'-' t. rXL'I~
5~ #~'" (/
~, /1 "-!- I ~ ~ -/; ,
. L- 4.h~
)UNT OF ACCOUNT ~ CASH
THIS PAYMENT 0 CHECK
BALANCE DUE 0 M.O.
TOWN CLERK
TOWN Of WAPPINGER
20 MIDDLEBUSH ROAD
iAPPlNGERS FALLS, NEW YORK 12590
09305
DATE ~p7/CJ b
. ,
$ \ /C \ t'E\
DOLLARS
ByJ
IJ / Cfbank~ou
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Reg istrar
for Copy of Birth Record
D Passport
D Social Security-Retirement
D Social Security-SSI
D Retirement
D Employment
D Other (Specify)
~~;~:~~~~I~I
NAME At7Yl If attorney, give name and re~ti ship of your
e 'C' I, . client to person whose record i~' quired
What is your relationship to son whose \J
record is required? I '\ }l I
Q Self D Parent D Other, specify j..-,,~
1 (11.. I ~I Ie 1/,1/11_ 1 J I _--+ (name of client) \
Te'I~Phone No. (~) ~t.~__l.i1~
Social Security No.~-l:J1J-~
First
Middle
Last
Name
~
!""t ~'C{.a...
Hospital (If not hospital, give street n ber)
Place of
Birth
First
-YO ()tAL.
Last
Father
I) L ,t
") 0 0,2 r
Number of Copies Requested
Enter Birth No.
if Known
J
Purpose for Which
Record is Required
(Check One)
Signature of Applicant
Date
l11J W2J 6 (..
MM DD YY
J 5 'R 7l n <) ~'J
Street ,
Ji(:{--{J -r ( Vl'j f' I -~
D( I \it!
-(; 1I S AI 'i
State
I .;;", ,S;- ? D
Zip Code
DOH-296A (11/94 ) Page 1 of 2
Date of Birth ~ l1LJ ~
MM DDYYYY
(Village, Town or City) County
VI
Do rt{l ( SS
Middle Last
Maiden Name
of Mother
Bps
Enter Local Registration
No. if Known
D Working Papers
D School Entrance
D
D Welfare Assistance
D
D
D
Veteran's Bene7ts
Court Proceedi~
Entrance intp '~r~ed /
Forces : ~\) \! \~
Driver's License
~ Marriage License
(relationship)
Application to Local Registrar
~ for Co of Birth Re rd
NEW~ORK STATE DEPARTMENT OF HEALTH
Vital Records Section
!
I Date of Birth
I
I Hospital (If not hospital, give street & number) 'I' (Village, Town or City)
I Place of I
I Birth I / J J
i f//W/~~<<S
Middle Last I Maiden Name First
~W &d I of Mother dr!kj
I
I Name
~e12
,6~
U l/)Jjj :/ Pl~~
MM DDYYYY
r
County
'P1ef<t~J
I
I Father
I
,
First
Middle Last
-ler~tf;te/
Number of Copies Requested
!
Enter Birth No.
if Known
Enter Local Registration
No. if Known
Purpose for Which
Record is Required
(Check One)
U Passport
LJ Social Security-Retirement
[J Social Security-SSI
D Retirement
Employment
o Other (Specify)
[J Working Papers D Welfare Assistance
LJ 'yhool Entrance
g Driver's License
Veteran's Benefits
D Court Proceeding
LJ Marriage License ~
Entrance Into Armed
Forces
your to person whose
re~is required?
.~ Self Parent U Other, specify
Telephone No. (~I'IIJf)I~~I-@l:5131
Social Security No.~I57J 1-~!3!ST
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
FOR REGISTRAR'S USE ONLY
(P..r6tocopy 10 and attach to applicalion form)
TYPE OF 10 / .
:~' Drivers License
:~ Jv
State ~ No.
D Other ID, specify
No.
DOH-296A (11/94) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Copy of Birth Record
I
I
I Name AJancc
Lt"
Date of Birth I nl~1 W ~
MMODYYYY
Hospita If not hospi
i Place of
I Birth 90 Mar Icet- S1r-e-ef
First
Middle Last
(Village, Town or City)
I . E( f{Lf{~
County
WrneSJ
t1r ~ f\JQ fuLi'
Maiden Name First
of Mother
LUUQ
Middle Last
Father
XJhv1
t, (La a
Number of Copies Requested
I
Enter Birth No,
if Known
Enter Local Registration
No. if Known
Purpose for Which
Record is Required
(Check One)
D Passport
D Social Security-Retirement
D Social Security-SSI
Working Papers
School Entrance
Driver's License
D Welfare Assistance
D Veteran's Benefits
D Court Proceeding
D Entrance into Armed
Forces
What is your relationship to person who e
record is required?
~elf 0 Parent 0 Other, specify
I Telephone No. (~) l?i-?~-~
Social Security No. ~-W-~
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
FOR REGISTRAR'S USE ONLY
Signature of Applicant
TYPE OF 10.
(Photocopy ID andattachto applicatIon form)
."0
Driver's. Lic ense
_No,
ID, specify
No.
OOH-296A (11/94 ) Page 1 of 2
Dear Clerk of the court.
I Maurice Vargas would like a copy of my son's birth
certificate.
Thank you very much.
Parents:
RECEIVED
JAN 1 3 2006
TOWN CLERK
Maurice J. Vargas -Father
Karna L. Mullin (Maiden Name)
(!(I}L~.~J ~VClU/(
Son's Name: Isaiah Matthew Vargas
Home Birth.
Born: 37 Cider Mill Loop Wappinger Falls NY 12590
Mail to/./
/ /':<:"/"'-:-..,/.--
...... ~/.. -"-
Maurlce'Vatgas
PO Box 284 Babylon, NY 11702 / 1/1 ,,~! i)LP
\'~'1
Thank you very much.
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I. MAURICE J. VARGAS 210 121 7
P.O BOX 284 09941181
. . BABYLON, NY 11702-0284 DATE /_ / /~O L
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