2008
Application to Local Registrar
Rf=CEIVB5r Copy of Birth Record
First Middle Last TOWf\1 · ::
Date of Birth LllJ l2.W WllihJ
MM DDYYYY
Yillage Town or City) County
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Name511N';:T (3 U R C C. P
Hospital (If not hospital, give street & number)
Place of
Birth U-J fI. r?P I N G (" R ff/J.t.5'1Vr
First
/J t/ r~ 1/ fSS
Father
HNi<I<!
Middle Last Maiden Name First Middle Last
C G u R C (a. of Mother f t 6 t< ( ),J G r; T F J Y 1'.1 /-f
Number of Copies Requested
/
Enter Birth No.
if Known
Enter Local Registration
No. if Known
o Passport D Working Papers 0 Welfare Assistance
o Social Security-Retirement D School Entrance 0 Veteran's Benefits
Purpose for Which o Social Security-SSI D Driver's License 0 Court Proceeding
Record is Required o Retirement D Marriage License 0 Entrance into Armed
(Check One) o Employment Forces
.0 Other (Specify) -ST/fR Pr<o er<A-fVJ
NAME
What is your relationship to person whose
record is required?
~ Self D Parent D Other, specify
Telephone No. d~) l2:.ITl2l-~
Social Security No. LLl2:L!J-l2iJ-~
Date
Signature of Applicant
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_ ~ MM DD YY
Address of Applicant
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Street F /lJ.. LS
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City Stcfte
(3/...(/j)
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Zip Code
DOH-296A (11/94) Page 1 of 2
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
Dru~ TR lICE~SE
008:08-30-34
SALVATORE,JANET;M
45 DEL BALSO BLVD
WAPPINGBRS'lFLS NY
12590
SEX:'F EYES, SF/Hi '5-08 CLASS D
END' R€STIiS
ISSUED ~O<lEXprRES. O&-3U-Ql
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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
Name
/)~
Date of Birth
lLl11llij
Y y Y Y
County
RECEI ED
Last
First
Father
&1
TOWN CLERK
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~assport WJ. k (Of '1
D Social Security-Retirement\
D Social Security-SSI
D Retirement
D Employment
D Other (Specify)
oN Bern~~~~~':'R~initto If attorney, give name and relationship of your
Nell/burgh, NY 12550-2645 client to person whose record is required
What is your relationship to person whose
record is required?
[JJ.zelf 0 Parent 0 Other, specify
Purpose for Which
Record is Required
(Check One)
Veteran's Benefits
Driver's License
Court Proceeding
Entrance into Armed
Forces
Marriage License
Telephone No. (~) likW-~
Social Security No.~-lLil:J-~
(name of client)
(relationship)
Date
WW
MM DD YY
Signature of Applicant
Address of Applicant
,-si tv ~ (U.
Street ~ f<-<A
c21~4L-- I State Zip Code
DOH-296A (11 /94 ) Page 1 of 2
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NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for COe>' of Birth Record
i\'.
First Middle Last
Name CuS~0..C\~
~ 1S\((~k(
Date of Birth I', I D IllBJ ll1USJ1j
MMDDYYYY
(Village, Town or City) County
HosPitalaf not hospital, give street & number)
Place of ID \ \ ' s&n ~
B" h Do\n \ '\/
Irt ~Pi~~W$ Nl
First
Father
FteJ.q'cl
Middle Last
~c~'\Mw
Number of Copies Requested
~
~ 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 perso9i~q~~,(~QJ..d is required
I IIOOll z ~nv I
(name of clien(J3^r?0~H
Purpose for Which
Record is Required
(Check One)
Enter Birth No.
if Known
What is your relationship to person whose
record is required?
o self(KJ Parent 0 Other, specify
Telephone No. (lR:.lf.J5J) l2.fllQj-~
Social Security No. ~-lill-l11:1l.:ilJ
Address of Applicant
\ D\ ~~
Street
.WlA.fr' (\ ~h ~HI1
City
Date
WW
MM DD YY
\ <1,,\ A.Q..,
\\3 f
State
17- ')1 D
Zip Code
DOH-296A (11/94 ) Page 1 of 2
~-k~<;s
Maiden Name First Middle Last
of Mother
~~~t;.~ k ~ lJ~,,- N~~\.+{-;~
Enter Local Registration
No. if Known
ref 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
Forces
(relationship)
'I'
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for CoPy of Birth Record _
D Passport
D Social Security-Retirement
D Social Security-SSI
D Retirement
D Employment
~ Other (Specify) 'tl L{ It I- e.. t II J.. ~ rJ <.S If I f-
~
client to person whose record is required
First
Middle
Last
Name L..L I L. ;6l/1?, rJ
Hospital (If not hospital, give street & number)
Place of
Birth
First
Middle
Last
Father
WILLI t11
ff:4.({N~
Number of Copies Requested
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
What is your relationship to person whose
record is required?
DSelf Dparent [2fOther, specify CAvl&;frt k..
Telephone No. (blclLJ) l3l11S-~
Social Security NO.lln:b:J-~~
Signature of Applicant
-....,
Date
m ldrJ 0 8'
MM DD YY
s-r .
;l\JJ 07(,;)..1
.
State Zip Code
Date of Birth ~ ~ ~
MM DDYYYY
(Village, Town or City) County
WA /(1. NCrrft ~
....-
r I1LL S
Middle
Last
Maiden Name
of Mother
First
tnfi~1/
G-^ IF FtlJ
Enter Local Registration
No. if Known
D Working Papers
D
D
D
D Welfare Assistance
D
D
D
School Entrance
Veteran's Benefits
Driver's License
Court Proceeding
Marriage License
Entrance into Armed
Forces
(name of client)
(relationship)
DOH-296A (11/94 ) Page 1 of 2
~ dO! '111 J-S"sJ
T(",' '\' ::-" r.:RK
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
CHRISTOPHER J. COLSEY
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
August 18th, 2008
Consulate General of Ireland
345 Park Avenue
1 ih Floor
New York, New York 10154-003 7
To Whom It May Concern;
Enclosed please find Certified Transcript of Birth DOH-2673 for William Bums.
The fonn does not contain the fields for Parent's Birthplace and Age at time of Birth.
However, this information is recorded in the original document maintained in our
Registrar for Registration No. 62 of District #1324.
Father: William Bums
Birthplace: New York
Age at time of Birth: 29
Mother: Mary Griffin
Birthplace: New York
Age at time of Birth: 26
Please let me know if you have any further questions or need any additional
information.
Sincerely,
, \j l f\i /\ : 0--
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With reference to your citizenship application please forward the following as indicated by an X:
o Your child/children's Original state issued long form birth certificate (i.e. showing parents names,
birthplaces and ages at the time of birth)
Your Original state issued long form birth certificate (i.e. showing parents names, birthplaces and
ages at the time of birth) - -
Original state certified copy of your extended form civil marriage licence application and certificate
showing your birthplaces and ages at the time of the marriage. It should also show your parents'
names.
Notarised and signed copy of current passport or other satisfactory proof of your identity e.g. photo i.d.
such as drivers licence.
Original or notarised proof that you are resident at the address on the application (e.g. current utility bills,
bank statements) no less than three items in all. (Please forward one more).
Original state certified copy of your father's/mother's long form birth certificate. (i.e. showing parents'
names, birthplaces and ages at the time of birth.) If no record is available, please provide a letter from
the Registrar's office to this effect and supply the church! baptismal record.
Original state certified copy of your parents' extended form civil marriage licence application and
certificate showing your parents' places of birth and ages at the time of marriage. It should also show
their parents' names.
If no civil record of marriage h; available, please get a letter from the Registrar tG thi.s effect and
supply the church record of marriage. Ifnot available, please get a letter to this effect.
One additional certified document e.g. notarised copies of father's/mother's current i.d. (Passport, driver's
licence) or original certified copy death certificate, if applicable.
Original state certified copy of your grandfather's/ grandmother's birth certificate in the complete form
which you may obtain by writing to the Registrar in the county in which your grandparent was born. If not
available a letter from the Registrar's office indicating no record of entry will be required in addition to the
Baptismal Record.
Original state certified copy of grandparents' extended form of their civil marriage certificate showing
your grandparents' places of birth and ages at the time of marriage. It should also show their parents'
names. If no civil record of marriage is available- please get a letter from the Registrar to this effect,
and supply the church record of marriage. If not available please get a letter to this effect.
One additional certified document e.g. notarised copies of grandfather's/ grandmother's current ID
(passport drivers licence) naturalization papers or original certified copy of death certificate if applicable.
Please complete and return Section E of the attached form together with photographs which should
be signed and dated by an appropriate witness - see list. You may not be identified by a NOT AR Y
PUBLIC - see list.
You omitted to provide photographs signed and dated by the witness to your application.
Please forward balance of to cover express mail fee in respect of your application.
The current fee for registration in the Foreign Births Entry Book is $217.00/ $83.00 (minor) by money
order/certified personal cheque made payable to the Consulate General of Ireland. Please forward a
balance of $39.00. We regret that personal cheques are not accepted.
NOT ARISED PHOTOCOPIES OF DOCUMENTS (OTHER THAN J.D. AND PROOF OF ADDRESS)
ARE NOT ACCEPTABLE
Processing time for registration in the Foreign Births Entry Book is 16 - 18 months.
Please note that if additional documents are reQuested, you do not need to re-submit those documents
which have already been checked and returned to you.
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7 August 2008
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Consular Districts in the United States
Please note the States for which each of the Consulates in the United States has responsibility and direct
your application to the Consulate which has responsibility for the State in which you are resident.
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Consulate General of Ireland,
345 Park A venue,
17th Floor,
New York,
NY 10 154-003 7
Tel: (212) 3192555
New York, Connecticut, New
Jersey, Pennsylvania, Delaware,
West Virginia, North Carolina,
South Carolina, Georgia,
Florida
l~~,\t ~~nsulate General of Ireland,
(, 535 Boylston Street,
Boston,
Mass 02116
Tel: (617) 267 9330
Maine, New Hampshire,
Vermont, Massachusetts, Rhode
Island
Consulate General of Ireland,
400 North Michigan Avenue,
Chicago,
II 60611
Tel (312) 3371868
North Dakota, South Dakota,
Nebraska, Kansas, Oklahoma,
Texas, Minnesota, Iowa,
Missouri, Arkansas, Louisiana.
Mississippi, Alabama,
Tennessee, Kentucky, Illinois,
Indiana, Ohio, Michigan,
Wisconsin
Consulate General of Ireland,
100 Pine Street,
33rd Floor
San Francisco,
C A 94111
Tel: (415) 392 4214
Washington, Oregon,
California, Nevada, Arizona,
Utah, Idaho, Montana,
Wyoming, Colorado, New
Mexico, Alaska, Hawaii
Washington DC, Virginia,
Maryland
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I HEREBY CERTIFY that J . III. Atal!phnldan of thlR InRtitutlon _uended th. dteeued)" (
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";1 {s. lfudb.r t'II:rtltrt that tuumatlo:! InJur, or poiflOnln<< DID NOT rlay an, pllrt In ('auRini' duth, and that dealh did nOt. occur Itl _n,. uaUf\tal
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PERSONAL PARTICULARS (To be filled in ~ Puneral Director)
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:~~GLE. MA RRIEO, WIOO\\:ED or mVQRCEO IWrhl! in ....onl} !I. NAME OF StlRVIVINn SPOUSE lIf ...ife, wi" mllld.nnam.'
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CTY REGISTRAR
TIle Department or Healtb doe. Dot certify 10 Ibe tNtb at tbe .tatemenl. made tbereon. as no InQolry a. to
th lacl. bae been provided bylaw.
DO NOT ACCI'T THIS TRANSCRIl'T UNLISS THI RA!SID SEAL 0' THI DE'ARTMENT 0' HEALTH 15
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Application to Local Registrar
for COe}' of Birth Record
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
!
RECEIVED 0 Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
o Other (Specify) ./co t-t/e I^
First
Middle
Last
Name /q 17
Hospital (I not hospital, give street & number)
Place of
Birth
Father
j~,4 / ?~J
Number of Copies Requested
Enter Birth No.
if Known
Purpose for~ch8 2008
Record is Rfr1~iJ~~9-- _
(Check One) .. , (LERK
Date of Birth ~ LJJ lL1.2lLW
MM DDYYYY
(Village, Town or City) County
;;Zc~~~'
Maiden Name First
of Mother
/10 tJ-c>//~
Middle
Last
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
,;? C LJ -T(C(.;/,f'/1 r1 e \/
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NAME
What is your relationship to person whose
record is required?
D Self D Parent D Other, specify 5 fe!/?
Telephone No. (LllJ) UJJ-LLW
Social Security No. UlJ-W-UW
Signature of Applicant
?(!Z-~
Date
WW
MM DO YY
Address of Appli
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Street '
Zip Code
DOH-296A (11/94) Page 1 of 2
If attorney, give name and relationship of your
client to person whose record is required
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(name of client) t (relationship)
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DRI\tR LICENSE
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;POOOHKEE'P$E NY
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SEX:'" EYSS: 14HT Stto CLASS 0
ENO:JIlES:r:; .
ISSUED '04.ta./):j tXPlREb 06-1l.()f
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14348120
NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar
Vital Records Section for Cop~ of Birth Record
First Middle Last I i I (h 11 ~mQ I G-
r) -r Date of Birth I 0 12.1 LLJiJ ~
Name I..::>fZ .. 13 v f1 ~ a '>( M MOD Y Y Y Y
Place of Hospital (If not hospital, give street & number) (Village, Town or City) County
Birth \}J r+ <f I 11.1 t CR 5 D lllc msf
First Middle Last Maiden Name ~ First Middle Last
Father fi<. i'J N f-. L .:Jft.y c. cjA of Mother G 1\ lIIeF liT K I NS4 ,J
Number of Copies Requested
I
Enter Birth No.
if Knov.n
L R.O.
Enter ocal egl~tl<!l
No. if Known > ~
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0:
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o Passport 0 Working Papers
o Social Security-Retirement . 0 School Entrance
o Social Security-SSI 0 Driver's License
o Retirement 0 Marriage License
o Employment
[~,. Other (Specify) i'\J ~ Y. 5' C6 lYl P fa 0 L'- e- K
}..jArvfE O/~ tv Ie- L !tflt-j< f-l 5 If attorney, give name and rel~tionship of your
client to person whose record IS required
Purpose for Which
Record is Required
(Check One)
. e:::. c~
~~re .liSistance
c:OCv etfian'~enefits
o Court Proceeding
o Entrance into Armed
Forces
What is your relationship to person whose
record is required? ,I I. ... ..._
o Self 0 Parent ~ Other, specify ~
Telephone No. (~~l1IYJll
Social Security No. LL1&lJ-@j-~
(name of client)
(relationship)
I
Address of Applicant
L /4 Polo\(
Street \ J
VC) u Citt 6\4.~ C fV Y
City State
11J-76
Zip Code
Date
~ 19Jj 0
MM DD YY
DOH-296A (11 /94 ) Page 1 of 2
,~~ Office 01 the New York State Comptroller
Thomas P. DINapoli
New Yorl< State and Local Retirement System
Employees' Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
Phone: 1-866-805-0990 or 518-474-7736 Fax 518-402-4433
E-mail: nyslrsinfo@osc.state.ny.us Web: www.osc.stale.ny.us/rellre
1111111111111111111111111
July 30, 2008
Ronnie L Harris
POBox 614
Poughquag NY 12570
In reply
Reg. No.
S.S. No.
Bene No.
Dear Ronnie L Harris:
This is the 2ND request for these documents.
refer to:
41100819
XXXXX8579
1
The following document(s) are needed to complete the calculation and
processing of the death benefit for Grace V Harris.
Please forward them to this office as soon as possible.
Please send us documentary evidence of the member's date of birth.
Enclosed is a list of acceptable documents for certifying the date of
birth.
Please send us a certified transcript of the death certificate with
the raised seal affixed showing the cause of death for Grace V Harris.
If you have any questions regarding the processing of this benefit
please write to the above address or call TONYA SMITH in the Ordinary
Death Benefits Unit at (518) 473-6494.
Very truly yours,
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Nancy Winnie
Assistant Director
Benefit Calculations and Disbursements
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Co~y of Birth Record
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Application to Local Registrar
for CoPY of Birth Record
NEWYORK STATE DEPARTMENT OF HEALTH
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V~tal Records Section
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D Social Security-SSI
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NAME~'~'~'''''-'' .. .. k ;/'~~ If attorney, give name and relationship of your
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Number of Copies Requested
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Telephone No. (If:Jt.tJ) LflM-~
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Signature of Applicant
Date
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Address of Applicant
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DOH-296A (11 /94 ) Page 1 of 2
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Driver's License
Court Proceeding
Entrance into Armed
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Marriage License
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