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2011 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record U,:,,.;~~;_I,:;;,,, ,;,' ...:~:,.~Jiiii... FEE: $10.00 per copy or No Record Certification. Please do no send~~OO%7 ~ [Q) Name of Deceased t\ e. ~-e.-o(', First Middle Name of Father of Deceased ~~~ First Middle Maiden Name of Mother of Deceased -\\.... \,. ~ , -~irst Place of Death 2io o,cl -\--lc~~\\ ~. Name of Hos ital or Street Address Purpose for Which Record is Required ~~c:."s 03 \"1- gooc:g' Social Security Number of Deceased l\.: ~~fS Middle ~i Date of Birth of Deceased D't rc. Icr'2.0 Month Da Year Age at Death tJ,).r. Villa e, Town or Ci ~7f- ~-\-~s.s Coun ~ What was your relationship to the deceased? -:V~"'4' ~ -\-e..- ~ In what capacity are you acting? 2~ e.(L\.L\-~\::>(.. If attorney, name and '2 of you Signature of Applicant ;..udo.-t.--. Address of Applicant z.gO Date Pd. I ~. t--. I N Y / /1,-/ I'LO f/ I 1; l.S i c) -1- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar Record FEE: $10.00 per copy or No Record Certification. PIe Name of Deceased ~ C 't\a.. ~ \ e. 'S -.)0 't- ~ First Middle Nam~ of Father of Deceased ~~ e..S ~ c~.\CL'Z.:Z_O First Middle Last Maiden Name of Mother of Deceased ~''-l t:r~ ~ First..) Middle Last Place of Death d- ~O 0 'C *~,€-u.),€-\\ R~ . Name of Hos ital or Street Address Purpose for Which Record is Required ?a... \0.- ~:-u) Last {:.~..I..: :t.,,::: Date of Death or Period to. be Covered by Search ~~\v \L\, z.DOS Social Security Number of Deceased Date of Birth of Deceased 10 0 3 r~ -z..o Month Da Year Age at Death w'~. Villa e, Town or Ci s J '-L~eSS Coun ~E..- What was your relationship to the deceased? Y(')Ul~ 1~ ~~ In what capacity are you acting? 9 lI. ~ U ~~ ~ If attorney, name and relations 'p of your client to deceased Signature of Applicant ~~ Address of Applicant 2 '8'D 1- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City ~.~:;; ~'\r~~\, l \ .5 ~\"-~ State ~. ~'f Zip Code r -z..59 D DOH-294A (6/2000) ~ COMMERCIAL DRIVER_LICENSE, 10: 619 084 918 CLASS B '~I$'SUli.. ;J . 21,DUGAN ';, ";~~c~c:~ E: P w.". R: NONE · ISSUED 02-1S-Il8 EXPIRES 02-G9-13 54588841 ~ 2 =rt:h IUZ-/€ ~ 1t1 jJJ-M- (JO!({Ll.-eJ 3-/7-c;)OO,y I\JEW YCJI={\( f.;lATI:. DE.F'AIlTIV\i::!\lT OF HEAUI\ Vital l~m~CII"cl" ~;l;!ctiDn _. _... -~'-Li~t"I~1<I "-l._UiJlIIIllt.UllIMPIMI'_"'l~WIlUl.I&IWI--'j)J-'~"" Application to LOGal Registra~ _ _ for COJ~Y of Death Recor_ F----------~ PLEI.IS E COM i'LCTE pQi'iM/";"D ENeL L_~:~E~:OO :::v~~"" 14e':J-~811':icatloll Please do n SE' . . t send casl)~~tr'~P2011 TOWN OF WAPPINGER TOWN CLER . ... .. ~~ ."......., ................ .......... ........ . ..... -~-~:~~~.-:.PI~E!\S[:PE{INT"Ofa TYPE ". '" '" .... . ,.....,..... -i~~~~-;;J De.ce~;;~d.--'---_.._--~----- --~-- -. . . Dale uf IJr~al'h or I::>eriocllo be covered by Search C A TH E:RI III i A. k'A R.6tt- JAN, )!::J-;.:2.tJ / I _..-.-.i!lst __._~__.__. n Micld\l:? Lac;! -- [\Iame o[ [= "1 1I 1 E) I. 01 [);'~~asecl ----.-----.-----.-,------.--- S(l~ial Security l\lumber o'f Deceased MAIZ\~ Cf</f\I1M1NS Ot_1-/S- ~l.f;J.-:J..-. Firs! Middle l_a~:I ._~.-._-_._--_._~._-_. Maiclen l\Jall\8 of MotlHcJ[' 01 DE-)cef:\:~ecl A 1V'N (UN#.t /\JOIN IV ) Fllsl. .___.~iddl~----_-._. Lm:L_.___ F.'lace 0'1 Death E LflNT Il-T wR(:lP ~L-~ W,q..~~ Ft.5. J~i;1rn(? oll-Iosplta~_~:.!:. StrE-let Adclrl~:;,~:~ _________~_____ VillaD8, TCI~1l ')1' l,i'l}l- l=>urpOSE!lor VVhlch Hecorcl is Ill"Cluil'i::c\ Date 0"[ Birth 0"[ Deceased J4tV. ~cJ. Montll Day /~;)tf Year Age at .Death 8~ Coullty ..:!:.9_~.,!TT':.~_._ E ~ 7 A..T E _.___.._.____--.-. Whal WiJ~~ your relatlollship to tilE' declO'llsElcl? _______..t;:;0.11l~RJ:fL- p ( t2 €L 7tlb. In what capacity are you 2\ctillg? ..______~-~~~. II altonwy, 1lL1111e clncl relcrl:iollship or YOUI' clier:t Ie ck!Ceasl"cI --- Si9f1i<tureUIAPPIi"Ult_..__~_t2..~ Date /- /~-// Addlessof A.Ppli;;~Hll ,_ &!L.. E-,,-Mf.t.L()[_S.L_W.4:LeL..:!P1~ ..Fr1l L C; IV 'I ~ ~ s.-9o -_.~.--_.__....,-~~~..~-~--.-..._,-------_._----------_. ...CO MPLETE FOR ..UEJ\TH::;>OCClJRB I:NGA'S OF. JANUAHy.t;1i988:.. .~~~,~---_._-_..._-------_. ----..-----,--..--.---. . ;~ . ......,.. : ',',"'; ,. .--'/: NUIllI:Kll' 01 copies requl=:~11:t:;!C1 with ccml'idE~liI:ia cau~)e of cleath 1\lwnber or copies requl?stElCl without cCI'rlidelltil\1 cause ot death --~'... .~.'.". .......-~--c~_..~---~~..-Tilj~A"'SE~Tlf.~11SfIN;I.\MF /.\N:r)--A-l5iS:I~13i).s. '.WH EFlF' H.EGO'I:;\n:S1:! OU'L:D..8E.:SE1~:T:,>jL- _____._.___....:-....:..:..:...:.__:~~~-;II--~.....:..I~-:..:..:.-~...:..:;~~:....-. ..-- '. ..... . . .. , . , l\JalTl e ___.____ Aclcll(:)sS .,__________~__~____.______..____._._,..._~.'_'R_____--.-...--.-' ---------.- __'__~.__,,_.~___..__._R._.__.._~._. -..---,----------------~ City _____._______._____~.________________________ Stale _ Zjp Code ---- ---/2 M c: --____.________......._.________n__._.._._.__..__._._ NEW YORI< STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ... ....p[eASECOMPL.ETEFORMAND ENCLOSEFEE'P 'P ... .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name 01 Deceased -ThcW1a~ -Po FII~;l Middle Name at Fatt1er of Deceased Mo.r . . pLEASE PRINT OR Date of Death or Period to be Covered by Search .~ IfTL Last -:Jc;JJr) \ ~ j 2C) \ \ Flfst Middle To..~1 GL ---.) Last SOCial Security Nurnber of Deceased I2,D- 40 -- GL\Z-~ Maiden Nelfne 01 Mother of Deceased H<::Ven C I CAn Fllst Middle Last Place of Death \.::, ~~ ~~ Name of Hospital or Street Address Purpose for Which Record is Required Date of Birth of Deceased ~ 23, \~ L\~ Month 0 Da Year Age at Death &\ ~'tcite~~ County ErJ of L\~ A~\~ What was your relationship to the deceased? \~ In Wildt capacity are you acting? c::::;.I,n \::o-.-h~ \ P 0 ~ If attorney. name and relationship of your client to deceased S. . ~ L\- 9- Ignature 01 Applicant \". ~ Date Address of Applicant 't=Q ~ \ "6/; . ~:)P\ ~c..~ ~ \ \ '?, ~ I ~ re.c... ~ .~VY\\ I ~ \- \9-\\ \ 2. set 0 .COMPLETE FOR OEATHSdcCURR1NGASOFJANl.JARVf198S:>: ~_ Number of copies requested with confidential cause of death Name ..__~_ Address City _n .._....__.H____. State ____ Number 01 copies requested without confidential caLise of death .....<P[EASS.PRINtNAMEANOAoORES$WHERERECO DOH-294A (f)/?OOO\ McCABE & MACK LLP J. JOSEPH MCGOWAN DAVID L. POSNER ELLEN L. BAKER SCOTT D BERGIN RICHARD R. DuVALL LANCE PORTMAN RICHARD J. OLSON MATTHEW V. MIRABILE KIMBERLY HUNT LEE KAREN FOLSTER LESPERANCE REBECCA M. BLAHUT IAN C. L1NDARS SEAN M. KEMP NOELLE M. PECORA LORENZO L. ANGELINO ATTORNEYS AT LAW PHILLIP SHATZ MICHAEL A. HAYES, JR. HAROLD L. MANGOLD ALBERT M. ROSENBLATT THOMAS D. MAHAR, JR. RALPH A. BEISNER JESSICA L. VINALL 63 WASHINGTON STREET POST OFFICE BOX 509 POUGHKEEPSIE, NY 12602-0509 TELEPHONE: (845) 486-6800 FAX: (845) 486-7621 WWW.mccm.com JOHN E. MACK (1874-1958) JOSEPH A. McCABE (1890-1973) EDWARD J. MACK (1910-1998) JOSEPH C. McCABE (1925-1981) DIRECT TELEPHONE: (845) 486-6817 E_MAIL.KMahodil@mccm.com ~~~~~~J~[Q) TOWN OF WAPPINGER TOWN CLERK 20 MIDDLEBUSH ROAD WAPPINGERS FALLS, NY 12590 JAN 1 8 2011 TOWN OF VV APPINGER TOWN CLERK APPLICATION FOR SEARCH OF DEATH RECORDS DATE: January 14, 2011 FULL NAME OF DECEASED: ANNABELLE B. KANE DATE OF DEATH: SEPTEMBER 13,2004 PLACE OF DEATH: 37 HI VIEW ROAD, T/O WAPPINGER, NY APPLICANT'S RELATIONSHIP TO DECEASED PERSON: ATIORNEYS FOR ESTATE OF THOMAS E. KANE, SPOUSE OF ANNABELLE B. KANE NUMBER OF COPIES REQUIRED: 2 (FEE FOR EACH COPY: $10.00) PURPOSE FOR WHICH RECORD IS REQUIRED: ESTATE OF THOMAS E. KANE NOTE: PLEASE FORWARD THE LONG FORM CERTIFICATE. THANK YOU. SIGNATURE OF APPLICANT: J~k~J KA THLEE~ MAHODIL, Legal Assistant McCabe & Mack LLP P. O. Box 509 63 Washington Street Poughkeepsie, NY 12602 ADDRESS OF APPLICANT: NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local ,Registrar for COe>' of Death Record .........................-......... ..........-....... ............... .. . ... - . . . . - . . . . . . ............... .............. ............. .......................-..................... .............................................. ........-...........-........................ ...........,.................................... ...;.:.....:.:.:.:...:->:-:.:.:.:.:.:.:.;.:.:.:.:.>>:.:...:,:,:-:,:,:,:,:':.:.:.:.:-:.;' ...................................... . ...............-......... ... :PtEAj$S::QOMPUGrS:]!QRM:ANP:eN;QUO$aEEe ......................'...............................................-................................ <-:.:-:.:-:::::::::::::::::::::::::::::::::::::::::::::::::;::::::::::::::::::::::::::::::::::::::::::::::::: ............................................ ........................................... .................................. . . .................... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~~~{}f)) ... . ......... ................. ........... .................. ........................... . .................. .. ........................ . . . . . . . . . . . . . . . . . . . . . . . ........................ . .. ................... .................. ...- . .... .. ........ ...... ....... ... ..... .:.:.......:.....:...;.;.:.:.:-..:... .. .... ....... ..{U~eW!As.e::~PB.N1FQ6:::1fYPe.:\)it: ......... ,......:: ...... .............. ... Date of Death or Period to be Covered by Search Name of Deceased rf\~rl '6- First Mi.ddle Name of Father of Deceased V~ ~ \?i"L t.. Last //09/11 Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last Date of Birth of Deceased Age at Death First Middle Last Month Dav Year Place of Death ~Ob UiJ.('0e~<-:- i\.~ LJ~pi"rsev-s K/IS; /1/'( Name of Hospital or Street Address Villaae, ~;;-Or Citv - Purpose for Which Record is Required L. 0. t.-./ r:= () Fa rc.. Q Vh e .I) t-. bu~c..ht".sS Countv What was your relationship to the deceased? Lc:.../.--.../ E", Fc).r-c-pfY'..:l ''1 f- In what capacity are you acting? L, E If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant .>-.....'-' ,)> --/)::> .5~ Date /1/ 4///0 / R {VI,rfJILbu4 L.. kd Uc.~~/(1jt"r<; FL./~/A/Y 1d-..5-c;.O ::{:Jr:::{:::t:?:::J:::~'::::::::::::::f:::::\:ftt:m::t::::\:r:::.:::':::'::':::':':':::::':'?":"':;'\':':':':~:::':::::.::;.:::.:;:.::t:';':::"':?:-=::;,':;:':':""':::'::r:::::::.:;::::.::.:.'.:,:.:.:.:.:.:.:.:.:::.:.:.:.:.:.:."\(:':::':"':::(;::':':'::~:r':"::':':;::::':::"':::::':':':':;:'::::::::::::::':::':::1::':':::':::::':::~::tt:::n:::t::::f::::tJ:::::::mm:::::::\:::JJJ:':{::{\:::::::::n:tJ::\:t:::::::: ~. Number of copies requested with confidential cause of death [R1 ~ ~ ~ ~'V..,1l~ [Q) - _ Number of copies requested without c(:mfidential cause of de ;. ~:' ~;~~f~jtm j~~~~~~j~}@t~~~I~~j~j;~~;~~;~;j~~~~~~~~~~}~~~~~@f~ R;j City State '~r Zip Code 12..s;~ DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. NaE,(o~~RAased IY1 ];2 ;~j)2/ C. First Middle Last Name ot Fa!her of Deceased I . ^ 4../ 9 I~ A O(?A T pI. I.. I First Middle Last Maiden Name of Mother of Deceased rJ1 A~ '1 ,c li.. PC' /1,4. I( First Middle Last Place of Death '71..c . /J ~! ;).b fJL6ARr/tJ 0 HrLL) K ~ Name of Hos ital or Street Address Purpose for Which Record is Required : ,i:: ,.,:....:: :t...:::t :::::: :.:. Date of Death or Period to be Covered by Search ~ JyJ/JOOO Social Security Number of Deceased / J.... '7 -18 -l '/7 r Date of Birth of Deceased L/ ;) c; Month Da Age at Death ;u" Year 79" w/f://'/H7CKS fALL.;- I tIj Villa et Town or Ci /J.. 0'2) lJ t:1....7CJI.." S5 Coon 50"( J/?oLl p1=.R of,,c'rE What was your relationship to the deceased? <; oIY In what capacity are you acting? 501'{ If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant Date _ Number of copies requested with confidential cause of death 2- Number of copies requested without confidential cause of death ... ... :.:.:.:.;:;::-::::..;.:...:.; ....... Name Address City State Zip Code DOH-294A (6/2000) :tI <0 (J '1 \ ~ )- C(j :; "'- \~ \ ~ ~ ,. ,.~. , . .. . l NEW YORI< STATE DEPARTMENT OF HEALTH Vital Records Sectloll Application to Local Registrar for COe.>' of Death Record 'pLEAseCOMPI..ETEFORMAND ENCL..oSEFEE . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name 01 Deceased fY\a VH CC . I F:I ~- J Middle Name at F altler of Deceased (j U\u1 Fllsl Middle Last Maiden ~er of Decetjd\ ~ \ Fllst Middle Las~ Place of Death d-vLP LLI\~'L~, Name 01 Hospital or Street Address Purpose lor Which Record is Required " ~~* What was your relationship to the deceas,~ ~ ~~ In what capacity are you acting? il'r--- ~ \ If attorney, name and relationship of your client to deceased -- Straub, (:dldLlJ!' ,~ lldlvey :-);) 1':d.~.;r \ L Lr :~lrC'ct Signature of Applicant Address ot Applicant .... .. ..' pLEASEPRINT OR TYPE Date of Death or Period to be Covered by Search V -e ipdt- Last V\A~YWVl \- q-I \ SOCial Security Number of Deceased I d-4 ,- d.--) -loY0) Date of Birth of Deceased Age at Death /-- '3 0 Month Da -3 \year -:r9 ~S uJ~ Villag own r City County 1- r 0 .- II ." COMPL.ETE FOR DEATI-ISOCCURRINGAsOF'JANUARV{'198S<'>><< ~~ Number of copies requested with confidential cause of death ....fl2. Number 01 copies requested without confidential caLise of death fR1~CG .. .. '''P[EASEPHINtNAMEANP>A.OORE$SWHEREREC Narne.__. ___ Address. City _ ________.__ f)OH-2~HA (0/2000\ OWN CLERK State Zip Code -, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record . .................... ........................ ..................... ............,..............................-. ..... '........,.................................,.. ...........,.......... .........,.........................,.......... ....................... ....................,.. . ... ..................., ...... ......,......................'........ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Date of Death or Period to be Covered by Search . e ra ~ d Last Social Security Number of Deceased First ..( Middle Maiden Name of Mother of Deceased c - ~. Date of Birth of Deceased Age at Death First M 't Place of Death Middle Se p+ Lt$ Da uq. Year Sf Name of Hos ital or Street Address Purpose for Which Record is Required ~Oh'o.( Villa e, Town or Ci D'e ~J u ~; W).a.. What was your relationship to the deceased? t(J I {<.0 In what capacity are you acting? l.d l~~ If attorney, name and relationship of your client to deceased Signature of Applicant ;?~ ,# . Lk;;;z, Address of Applicant ( :oj fot rJ L.,.) N..L uJa WPl ~~ I' .s Date I /'1 It! " I , h.il~... IJc:clI) --L Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name City State tv (f, Zip Code ~1ry() DOH-294A (6/2000) f y NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ."_"'EflQb" ... .. . .' ,','. .', ,". .-.... ... .. .' . . . ,. . . ...... .',' ...... .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Nam~ of Deceased ~~^ t?:d~ro First Middle Last Name ~~th~~~ Deceased ~~\ l'oL First Middle Last MaideJ')Name of Mother of Deceased-r. n , l'O~~ lit{ 6'\0 First Middle Last p~ofDeath _I \ I \ t::\~ W- WOlff I es Name of Hos ita! or Street Address Purpose for Which Record is Required rW\6~\ +b~ ... . .. " ,'. :;=::.:." . ::::::,':," Date of Death or Period to be Covered by Search 6~ (If '0 II Social Security Number of Deceased 05S- dG--7~D1 Dateo Sf of ~~e(ed ~ ~ Month Da Year Wl\ff~ yXcl'.s ~ l.s Villa ,TbWn or Ci Age at Death ~C/ fl-tJ.ess Coon _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of deat Name Address City D~ (6/2000) State Zip Code NEW YORK STATE DEPA~TMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record .. ..' '. . .. . ............ ..... ....,......... .......... '" ...., -... -.-. . ....... . . . . . . . .. , . . .' . . . . . . . . . . . . . ,.. .........,................. . ............... .................,..... dd' . . e' 'UII:lI "_d_Y""'_'_ .. :::'a~~E':Q". . w<<t.'~::liiO:rWD .::~:::~L"'.. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ c I rt p I) A First Middle Name of Father of Deceased a ~vt 11./ U First Middle Maiden Name of Mother of Deceased {(IJ~hf-H 11j{) (.."......Ac.)J, fJtZj), First Middle Last Place of Death .2.q () c?.. t-CHt.. (vi ,) Ut II!> tZA Name of Hos ital or Street Address Purpose for Which Record is Required .. I' . ,'. .'. :::: :.:: .' ",: ::~:.': Date of Death or Period to be Covered by Search c: L., J) A 5 Last 9/19110 Social Security Number of Deceased U f\ 8 I, III (2..(:> I Last 09& ( 1?.2 () Date of Birth of Deceased Age at Death Month Da Year IV Y J-< S-,\' () J) u -J c ). e..l S' Coun What was your relationship to the deceased? D f1 i./ J /14 c y In what capacity are you acting? l-l- -e ( L.-t. f 0 r- If attorney, name and relationship of your client to deceased Signature of Applicant ;..f~ ~ /J~ Address of Applicant 5' It /.I Date 1/ .5 i l d _ Number of copies requested with confidential cause of death -L. Number of copies requested without confidential cause of death Name Address City w Zip Code DOH-294A (6/2000) \ rJ-.-'-- \ ~ . \)\J u f= c::L,= <> ~ D -0 (-' -- "'-0 D -- ......... k. C> .\) v, l\ll=:W ycm\( ~~TI\Tl:: DE.F'/-\F\TI\I\[j\JT OF: Hi:::ALTI'! Vilal l=lecCllcl" ~';m:t1on ... -......,.". _1~'-l.IIliIIJlllI,IJ"""I,--I_...IlII!~-.~-'''''' := ',. - ., - - ,". " "",' .... ,",.,,' ..,-.' '.". . " . -. .', . ' " - . . ,,' ... . -~.---"._-_.---~_.~-----_.__.~~ ",I" 1;i3!\SiE :PFtlNT:Oll TYPE ~Date of Death or l:Jeriod to be Covered by Search 1\1 E\lTl [C.! 01 De.ceased .Do,qA LE 11 1::112,[ Middle -_..---------~~--~--_. I\Jam!:: ClII=alll!:!lcyl Deceased B V~r...Et< .JAN- 13. :2011 -_._-~._-_..~-----_.~-- Las[ So~iC:\1 Secmity l\lulliber 0'[ Deceased df&,f- ~" 3<:t90 Leofl/4/tD 1=II's\ WH,TTetl! Middle Last -----~"-~._-_...--------_.-. lVIaiden I\lame or Muther 01 Deceased Dale or Birth 01 Deceased .. LEtJo~fi C.oE 11 f'tZ/L ;;19, _~~__ Middle I..Flst Month Day r:'lace 01 Dl:lath il-flAl-;-,lf-r -'w;'/,;'INCre""i5 i=/ff-L,'7 W;:;f'~ 1='->. J~arne 01 Hospital_~~ Slleet Acldre~',~~ . VillC1~;le, TUv',;n or City I:JUlpOSE\ tor Which 11ecCllcl~=;;~;~i--------------- /931 Year Age at Death '79 .purc:.lle~ S County _________...70 ~f_T_T~E' __1fE. S T A T.~---- What Wi\~; youllelallolislllp to tilt' c\ece2\sc:,cI'! ____EugJ~ ~PA-!.. l> i ~ e t: T~& III what C(11)E\CII.y ,:Ire you C:lctill~l? _________ 5 ':3,M~---- If at\olllOY, Iklllle c\l'1c\ relatiol1::;hlp 01 yuur client to c1(!clJasl~ci_ ~---- Slgna'ure 01 Applicant ~_..:.~~-"_~,Q~./..~~ Dale 1- ILl - /1 A del less 0 I A pp II C cllll u_~q_...ff..,J_!'!/lLI!L--:?T -:_t__.J&..tI-1' I" II"~ P ~ I 1-5 - AI Y- _______'-coMPLfn~~FQ.!3-nE)~IH~-PQ~~URRINGAS OF JANUA _,_.._ NUIllI)[:r 01 copies reC]ue~:;I,ccl wil:h (:cJI'Iliclerltia! Ci:lU~)8 or cleath ---------_._.-.----~---~.. ~-_._--_."--~-~---_._~-------------._._-~-----------_. 1\lwT\ber of copic:\s lequ?sIE!C\ without COllficlelllli\\ caUc?8 of c1ealli JAN 1 4 2011 TOWN OF VV APPINGER -.....,-......---.~.~------------~..__._----_.__....------ _~=-_=~.==J~LI3iI?-~?RTi~ft.Nt\ME )_\Nl)-AI50111~t;swHEHE.HECORDSHOULDBE..S~....... ------;v-------------~~- , , l\lame _______.______.__ . -~--_.__.+----_._---_.__._-_._..._--_..-..-- Adcll'l:Js~:i ---------.- --- -----_.._.~-------_._+._._-~-~_..__._-_._------------- Zip Code - - City ____~____-__________________..______ State .---...~--~----~--~.._--_.~..,--------_.....-.---_.--_.-.--- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record - pLEAsE COMPLETE FORM AND ENC.COSEFEEP - - -< FEE: $10.00 per copy or No Record Certification, Please do not send cash or stamps, PRINT OHTYPEP Date of Death or Period to be Covered by Search ~ ~n, '23"LG\ \ Name of Oeceased - \ ~ ~<T-=\\ First Middle Last Name of Father of Deceased ~~~ First U Middle Maiden Name of Mother of Deceased LA {\ kvt::v'\l V\ Middle Social Security Number of Deceased ~rro\\ Last 'bG22- - 51 - \ ~2. First Last Date of Birth of Deceased Age at Death F"""e;o. cS I \'1 Li-=1- (0 ~ Month Da Year Place of Death - ZL-\: ~-~\0\\J'e.7J~~ V'Jc.tfP,~~'~\\S Name of Has Ital or Street Address ~own o't--cly Purpose for Which Record is Required . . -E==~- ~ L\'~ 'A~-(\~ 'UA...~~ County What was your relatIOnship to the deceased? ~V)Cf'O...' D\'\ec_~ In what capacity are you acting? en ~'V\ \ ~ C5 0~W"\ ~I LL4 If attorney, name an lship of your client to deceased ~ Signature of Applicant Address of Applicant Date \ 2.sri C) \ - 2 (j, --\ l - COMPL.ETE FOR DEATHSOCCURRINGASOFJANlJARV1198S> -- @:::Number of copies requested with confidential cause of death ._~ Number of copies requested without confidential caLise of death lRi~~~G~~[] . --Pl.EASEPHINtNA.MftA.NO>ADORES$WHERERECOR Name ___~. Address City _____ State Zip Code DOH-294A (6/200~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Seclion Application to Local Registrar for COe)' of Death Record .pl..EASECOMPL..ETEFORMANO ENCLoSE FEE . ....... . ". . '.' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased K ?I~ \1)1 'PL..E.ASEPRINT OR Date of Death or Period to be Covered by Search <::::= , Middle B~~"-I V\ Last Name ot Father of Deceased E \ VYtc: r 6:" ::::"\. First Middle B\'C:> ~"-.)V) Last No....;. l \ \ 9aS I Social Security Number of Deceased I \8 - 09 - 2058 Maiden Name 01 Mother of Deceased \/'0\0 ~~ First Middle Last Place of Death 10 4-X-1 ~ (2)\ c-ee..-i- Name of Hospita~Street Address Purpose for Which Record is Required \ \e.~-\ 0.. c~ 1\ k. it,5..Ayo....nc:::....z. Y)e~ed ~ I Date of Birth of Deceased Aw::l 2G2 \915 Month 0 Da I Year Age at Death 7'~ bi'.A ;-cve~ County o V""\ N\ ~e\'S::. What was your relationship to the deceased? ~ In what capacity are you acting? 0.") m.i:/ ovu~'1 If attorney. name and relationship of your clierJ to deceased kho\l{"> Signature of Applicant Address of Applicant (a" . $. Date ~ -;/011 -r=- nd,""-nl~\ \ NC 2801"1 TO ~ . .. 'Pt.~ASEj:lfnNt'NAMEANDAl)DRES$WHEREReCOR ....COMPl.ETE FOR DEATHSdcdURRINGAsOFJA _L Number of copies requested with confidential cause of death _____ Number at copies requested without confidential caLise of death Name n______ Address City _________ State Zip Code Jt1/~ · OOH-294A (fi/2000) lJ-1#. ~, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~t~ R, Middle Name of Father of Deceased f?-.-o ~ a. (' I '0 G /1 eJ-f, . First Middle Last Maiden Name of Mother of Deceased f} . I'1tt{0\ I>or\. Vi {l) First ..J Middle Last Place;Dea4 Ar~~or~ Df',' ve Name 6f Hos ital or Street Address Purpose for Which Record is Required ",' ',' ,',' . ,." .... .. ,- .;.:' ..... '::::.:.,' Date of Death or Period to be Covered by Search L+~ul\~o Last lo~ -2'2- 7-0(0 Date of Birth of Deceased ~<j' O~ Month Da Age at Death I r"3( Year -;1 j)l4ll'he SJ Coun What was your rela onship to the deceased? r: jII (I'LL I In what capacity are you acting? ~ . If attorney, name and relationship of your client to deceased % J~' Signature of Applicant lA/,.....,. Address of Applicant L 'i J-. - I q c ~ ", f) //'e.L-fO( Date &l\JQ- ~~~./I"? Z~O{~ I AI, (37 _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A &~O) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Cop of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Name of Deceased ~ark Alan First Middle Name of Father of Deceased Kenneth First Middle Maiden Name of Mother of Deceased Sharon First Middle Place of Death Fishkill Name of Hos ital or Street Address Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement of the deceased PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search Luhcs February 18, 2011 Last Luhcs Last Social Security Number of Deceased 485-88-4070 ~oore Last Date of Birth of Deceased 10 20 Month Da 1961 Year Age at Death 49 Wappinger Villa e, Town or Cit Dutchess Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? ..-.,_.<,~ Signature of Applicant Address of Applicant Date Februa 18,2011 COMPLETE FOR DEATHS OCCURING AS OF JANUARY ~ Number of copies requested with confidential cause of death [R1~CC~~vj~[D) _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHO LD BE Name Address City State Zip Code / DOH-294A (6/2000) rf NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record H..............:../.......P\ll.~$e~QMPcet:erQ.M*NQENQCQ$l$5EJ$/< FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased p~A/AZ-P First Middle Name of Father of Deceased C~$ff"e EU~rt:?N First Middle Last Maiden ~ame of Mother of Deceased t-1A'c;//V /.1'9 e; HriFU/~ D First Middle Last Place of Death / t:J t,dA/ r /T;;1( tll" c:'! r Name of Hos ital or Street Address Purpose for Which Record is Required ,;vIciPS rD oVA!rPN Last Date of Death or Period to be Covered by Search ;z.. . tP . If Social Security Number of Deceased 3~ . 3g"'. :)7~Z- Date of Birth of Deceased Age at Death /"2- Month 2-3 Da 7'-7 Year ~-:s Wl'f7?hA/~ar Villa e, Town or Ci DtJ V- Coun ~rrM/L- What was your relationship to the deceased? In what capacity are you acting? F P If attorney, name and relaf shi .................................................................CQN.iPLEiEEQRDEATHSOOCUfr......GASOFJANUARVd19saUi..\(?(.................................. -7- Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Date .:z,h k , , "2- S--~ ~ Signature of Applicant Address of Applicant /V' Name Address City ':'.P\UeA$SPAINllNAME:ANOAQQBl$$$'WHeaette:< State Zip Code DOH-294A (6/2000) j NEW YORK ST ATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Nam~eceased / , yC11'"\ L r'cJ,~" berf2I First Middle Last Name of Father of Deceased LL 1 Jcr~~t.. rr-r/;r11 First Middle Last Maiden Name of Mother of Deceas.Jd CAr;ff,~ ~ ""... First Middle Last Place of Death C.l #f?({1~( ,1/~'/ ,(J;r 12.:>( tJo/fJ~tf'"/ fr((/- /^( (.2~ Name of Hos ital or Street Address Villa e, Town or Ci Purpose for Which Record is Required ::: )81., ,t....:. Date of Death or Period to be Covered by Search .2-.-?1,- (( Date of Birth of Deceased , ~ 19.L'! Month Da Year Age at Death ~(' Social Security Number of Deceased (oo.-22-7JP #/d-<.r/ Coon Date _ Number of copies requested with confidential cause of death X Number of copies requested without confidential cause of de~th Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ............................,......:....;.:....:-..-:.........,. .... :::::::}){:~:}~:~<:}::~:}>:::::::::::::::::: .....:.;.:.:.>...........:. Social Security Number of Deceased 'or)-)v:-Q7Tb Age at Death tFr FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name}fD. eceased ~r6(r;,. ~ 7~rCIt~ First Middle Last Nam~ Father of Deceased 4'\:1~1 ~'J~((<- First Middle Last Maiden.N. ame of Mother of Deceased, Date of Birth of Deceased /I'r, <- fr/< , (~ Ie ILl Y I ~ q First Middle Last Month Da Year Place of Death 3 b ~,I3c'~ 1~ ~ ;fty-Ip 7 ..~..__-;.:__VClf"'V{ 61ft Name of Hos ita! or Street Address "ilia Town or Ci Purpose for Which Record is R~r, ( H:/N .. I .. . . ,. '" :::.:-:... .,:;::::......: Date of Death or Period to be Covered by Search .;2- -- 7-- ( ( ~~I Coon What was your relationship to the decf:'.~?" In what capacity are you acting? '. ,. /z::+r~ If attorney, name and relationship of your client to deceased ( c1/ ~~hlf~ Signature of Applicant ~... .I?'h~ =-- Date .;2-r-t{ Address of Applicenl :?.2 "t:. .:)Sc.).,1 ~1I0J7;.i. _ Number of copies requested with confidential cause of de ~ ~ ~ ~ ~VJ ~ \Q) _ Number of copies requested without confidential cause of Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co~ of Death Record elili5.A$SOOMPCI$"tEFO:AMANPEf,lQI4Q$SFEE)/<< FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ...<1 n tho nv r:: First / Middle Name of Father of Deceased F<.~ + r 1 t!..k. First Middle Maiden Name of Mother of Deceased P{.)IYlLniL-d. f~tru t-<ie'11/ First - -Middle LasT Place of Death --r Vlt ~ .<d" A <LOi defY) VI S 1- Name of Hos ita I or Street Address ..:.J Purpose for Which Record is Required Date of Death or Period to be Covered by Search POi ~'IO lasT S - .if - 20 II Social Security Number of Deceased ~elo Last D1D - /~- /11 ~ Date of Birth of Deceased Iq~~ Year Age at Death II . Month /~ 87 'v'\ta-JOO j n ae:.r Villa e, TovJn 6r Ci U J)ut~c.30 Coun What was your relationship to the deceased? '127~ -- I In what capacity are you acting? C. e. rh J..- I ~ n~ r6\ . If attorney, name a~d relationslJip of your client to deceased A I .ge-rYi{~ (tj6f'. Signature of Applicant 11 Address of Applicant .,.-. ...........>.........>))..............................:i....COMPLETEFOBDEATHSOCCURRINGAS.OEaANUARY1@19Ifi.....))..>.< <.................................................... .. ~~umber of copies requested with confidential cause of death .. .. ... ......... ... ..... _ Number of copies requested without confidential cause of death State ....eUl$\$SP$INt:NAMEANOAQQBS$$'WHE..I$AE .... Name Address City DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record :...:.:.;.;-..;.............................:.:-:.;.:-.';....-:............... .:.:.:.:.:. p~SBf," ........-.:..:-<:::::.;.::::;:..;..:'::::-:..:::.:.:::..:-:<.:.:.:-:.:.:.:. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. N\1e of Deceased J ~ h 1(1 )\t t;~ ~dle N~ t:-taIs Name of Father of Deceased .1,,) J - 1/1 GtL9~ 'Prt >I N~ l{ j.e 1/ I Firs Middle Last Maiden je of Mother of Deceas d Date of Birth of Deceasad f1 ;J~rst Middle Last Month Da 57~~ /.Me!- M I/)~ Name of Hos ital or Street Address Villa e, Town or C' Purpose for Which Record is, Required i I +Or lAy tLb-r~er9 es; ',:, :.,...1. Date of Death or Period to be Covered by Search I ()~ Z-zr 10 Social Security Number of Deceased Year Age at Death 1~ )tI-kie:-~s Coon What was your relationship to the deceased? In what capacity are you acting? SlY " attorney, name and re~iP of your clie It Signature of Applicant A --.: Address of Applicant :::; _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record .,. ...... """""<PLeASI;;CbMPLETEFORMANDENC.t.OSt:FEE>> FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ... -. ".' .'. ...--...... ....... ..... ".. .. > pLEASE PHI NT.OR Type:,:'.'" ....:.......>:..::.:..:.:.:::..::::::::::.::::.:. ....:: .. Date of Death or Period to be Covered by Search Name 01 DeCeaSl:ld C\t\Y\~ ne.. J . First Middle Name of Father 01 Deceased ~J'V\M Fllst -. - - , Middle ~~vin\\ Last ()-{ - o--/t' \ \ C~YD{,~ Last Social Security Number of Deceased ovy . V Z- - ~:::r S9 ~ Last 0\ - DI-\ -. \0 d9\ Month Da Year Age at Death <32- Maiden Name 01 Mother of Deceased \2-0~ First Middle Place 01 Death . \ 0 C..6\ C5"{\,~ ~ v-C I A\* t'9 Name 01 Has )ital or ~- Addres'b I a Purpose for Which Record is Required eW- D-Y \\~ 6.-~\~ Date of Birth of Deceased ~r\~\fS~ ~-\-l~(j T own or City Count What was your relation.~hip to the deceased? -flAk 0\11 Q 0 1 ~ In what capacity are you acting? ~~lk-o? ~LV\.-li~ If attorney, name and relationship of your client to deceased Signature 01 Applicant Address 01 Applicant StraulJ, Clld[,1I1() 8, llalvey 0"':::; Lust \ld:l~ Slrcet PO l)u:>; i:ll Wa )in Jers Fc111s "y 12590 ':'COMPLETE FOR DEATH S"O'CClj'R:R'1 N<:i:AS OF JAN'>""'" ~ Numher 01 copies requested with confidential cause of death ~ NlImber of copies requested without confidential cause of death APR 26 2011 ::.P~I;ASEp.RINTNAMeANPADQREs$WHERe.Re~(jR '. Name Address City ~____ State Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record PLEASE COMPLETE FORM AND ENCt..OSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Richard A. Carnes First Middle Name of Father of Deceased Lewis Carnes First Middle Maiden Name of Mother of Deceased Beatrice Mckeown First Middle Place of Death 394 Old Hopewell Road Name of Has ital or Street Address Purpose for Which Record is Required PLEASE PRINT OR T'VP6 Date of Death or Period to be Covered by Search April 23, 2011 Last Social Security Number of Deceased 081 38 6506 Last Last Date of Birth of Deceased March 20, 1948 Month Da Year Age at Death 63 Wappinger Villa e. Town or Ci Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? Funeral Home If attorney, name and ralabons iR f your clie f to i7~ - ~ ~ Signature of Applicant JV(/'i1~~.:. Address of Applicant Date 4(p311/ Hopewell Junction NY co 19$8 Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death pa;; SPRINTf.fAME.. 'NOiADDRE8S WHERE- eCORD.SHOULDBE e Name Address City TOW~._I T' , Zip Code r:\ 26 2Ul1 /',PPINGER ''''~I "-:m~ERK ---, State DOH-294A (6/2000) ~i~ . NAHLEN tETER,W II . $1.flOBERT I,.A .. ~IPPINGERS FLSNY 12590 DOS: 03-07.<<11 sex M EYES: GR HT: 5-11 E: NONE'. R: B ISSUED 02-24-10 EXPIRES 03-07-18 j 0 -eYe!) - c9/J/ 0 b ~)-"!/) :tf39 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record :::~::;::::::::::::::::::::::::::::::::::::::: ;::::::::. :::::;:::::::::::::::;::: .. ......,......... ...;......:.:.:.:.:.:.:.;.:-:.;.: .................,.,.................. .... ........, P'," . ............... .,.............. ......,............... ........ ...........-............................... '" FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Namerl.f Efeased retef\ irst Middle Name of Father of Deceased !fe-^ r 1 [ }./ f; f}\ Ie. ~ &- k- .I-. First Middle Last Maiden Namp of Mother of DeCjSed I (Y\dcJ.rtd ))<2-(' er,'cr-- First Middle Last Place of Death iZ L Pr ,...1"'1 u... R.. S / ' rt- l.9- S~l.tk.. Last .' '.' I .' . . . . :;:::.::., ,,::::=:.,':. Date of Death or Period to be Covered by Search 4/;o/d-RI/ Social Security Number of Deceased c2 Date of Birth of Deceased /~J9 Year ID9 0] Age at Death Name of Hos ital or Street Address Purpose for Which Record is Required Je&A- L Ie Month Da /../-0 f\A fi Wit fP,' ,J '& (;Jl. Villa e, Town or Ci {It L{, ~ Sl bu-kh eSS Coon What was your relationship to the deceased? F~ N- rC"- { I (~L...{.- I'-- In what capacity are you acting? If attorney, name and relationship of your client to deceased J?~~k- E:~w,4L~ h- :7""A1"^-:4 ,1 I Signature of APPlicant~(; (I.~ ____IL. FJ.-/\ .f-IC.) C It APi L Date illllll Address of Applicant /41-J.-~ No/tAu-I" BIt/d. flv.S/-I/I..j(r /J'::{. /135~1 _ Number of copies requested with confidential cause of death li- Number of copies requested without confidential cause of death ::;:::::::;:;:;:::::::;:;: Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ............'>>.pceAsEcbMPLETEFORMANOENCLOSEFEE> ..... ... . . . . . . . . ' . - .. ..... ....-...' .-. '-", .,....-.. ..'.... , FEE: $10.00 per copy or No Record Certification, Please do not send cash or stamps. Name of Deceased . \ --,- -.....; cV\f\ '-l . First Middle Name of Father 01 Deceased ~ Middle Maiden Name 01 Mother of Deceased N \ \c\~ ~n'c.e.-" ,'c- First Middle Last Place 01 ~eath . \ 21 ~o\c\ VdO.-q Name of Has ital or Street Address Purpose for Which Record is Requiret . ~. of L~R- ....................................'............. PLE.AsEFiRiNT.cH:fT'{PEt>... :::....:..:.........::..:.. .. .:..:::':",<.:::::..,.....\::::.::.::::..,........ 'K. ~ ,.oate of Death or Period to be Covered by Search r'1,\\(oJ\cV\ \=eb. \\.2<:J\\ Last \V\, \ \<.o-J \C- \;" Last Social Security Number of Deceased Date of Birth of Deceased ~ G\.l{ /11 \0\"32- Month U Da Year Age at Death 'T5 , City ~~~ Count Villag , Mk\{~ What was yoltr relali~"?hip to the deceased? fO\r""-~ In what capacity are you acting? CV\ ~ .y)?\l I 0 If attorney, name and relationship of your client to deceased \:::1 ,ec~ G.iV1 ;j Signature of Applicant Address of Applicant 3- \ 4-\ \ ",...,..'....... .'COMPLETE FOR DEATHS OCCURRING AS OF <.IAN : ....... ... ....... .:::::':<:::::':. "::,,,:,,:, . :,".,:::: ;;:<:\,;::,;:;;':::r:<\::::t..;:::':/:" umber of copies requested with confidential cause of death [R1~CG~~~f~~ _" Number of copies requested without confidential cause of death ;:.Pl;:~ASE..P.RINT.NA.Me.:ANtj.AODRI$SSWHERE.R.EPOftP$HOQ Name_ Address City ___" State Zip Code DOf-/"294A (6/2000\ ... NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ,~ .~_~~I8OLO$E:qe:::i ... ....-......,....... ........"....... ." ;::;;;::;;::<:::::?:::::::;:::::;:;.,. .... ............................... . . . . . . . . . . . . . . . . . . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. First iddle A Name of Father of Deceased . :::':.::RI-:::t.:.. Date of Death or Period to be Covered by Search t;; ticS J - I g- 1 \ Social Security Number of Deceased y '6 S- - g s - ~O?O Last Date of Birth of Deceased Age at Death Name of Deceased First Middle Maiden Name of Mother of Deceased First Middle Last Place of Death / 0 9 4 0(1 C; - t.. 0-1 ;ll r IS VI J<. J L L lilY Name of Hos ital or Street Address Purpose for Which Record is Required Month Da Year J::LSJ..~ Villa e, Town or Ci Coun .D~,v I fJ L What was your relationship to the deceased? E f.. - S.po J s: e In what capacity are you acting? 5 eLF- / 8e.Jf\ e.F f L I ""( If attorney, name and relationship of your client to deceased Signature of APPlicllnIr ~ G. . ~ Address of Applicant 0 ~. ~. -L Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death MAR 2 8 2011 OF vVAPPINGER Address City cO, D ff-tc.. e (?fl f If State f fl Zip Code \\PSo 1 - r) f{, 1 DOH-294A (6/2000) ~+ 3!d-f , '# ~ Prudential ....... 'Vr-uDe-,,-..Yl:\ AL ~\(~. ~ .0 "Ou)l 5 ~ LJO SC--~~A. 1-B50~ Prudential Retirement The Prudentiallnsurance Company of America 30 Scranton Office Park Scranton, PA 18507-1789 1-877-PLN-4MTA www.retirementllrudential.com Patricia Luhcs 602 Meadowridge Circle Beacon, NY 12508 Plan Number: 300186 Sub-Plan: 001690 Reference Number: 30018684070 Decedent's Name: Mark A Luhcs 5.5 t-J Lt\-e-t L.!? L....I 0'10 March 15. 2011 Dear Ms. Luhcs: We have been informed about the death of your ex-spouse. Please accept our sincere condolences for your loss. My goal is to make the processing of your request for death benefits as prompt and convenient for you as possible. Our records indicate you are the sole beneficiary for the account referenced above. As the beneficiary of this account, there are special rules that apply to your receipt of a distribution from this account. Penalties may be incurred if the account is not distributed within the timing standards set by the Internal Revenue Service. As a beneficiary, you have the same rights as a participant with respect to annuity options and making exchanges between investment accounts. If you would like a prospectus or related materials, please call us at our toll-free number. At this time, I would appreciate your help in providing the following so we can process this claim: . In order to process a disbursement, select an annuity, or set up a separate account in your name, we need an original or certified copy of the death certificate. If the cause of death is listed as 'Pending Investigation' or 'Undetermined' it will not be accepted. Prudential will require an amended death certificate that indicates natural causes, accident or suicide for reason of death, or a police report stating that the beneficiary is not a suspect in the death of the decedent. l've enclosed a form you may complete and return to us in order to have your portion transferred to a separate account under your name and Social Security number or paid in a single sum. If you elect to set up a separate account in your name, please complete the Beneficiary Designation Form. You may request a disbursement at any time in addition to the required minimum distribution (if applicable). It is our understanding that any funds paid to you should be reported as ordinary income for federal income tax purposes for the year in which the funds are received. You may wish to consult with your legal or tax advisor if you have any questions regarding the tax treatment of any payment, as Prudential Retirement cannot offer legal or tax advice. .. Application to Local Registrar for Co of Death Record .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ., ... ?)fr\rtrrt~\~? \\\\t~t/:;(~~:t(:~~f:j}::: . ... ..........PL.EASEiQPMRU'.lFOBU.....!.EHCUOSE..fiES:.m::.ji(:::i/fir'}, :~:t:;::;;:::::::::::::{:::::::~::::::::::{;::~::::; :.......;.:.......:...:...:-:.....:.:.....;..... .' .... ...".."... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. First iddle A Name of Father of Deceased ,,: ....... . ::.. :.::BI81:.: . :. .imYl&j('fifltj.;;:;..:;;:(!!t..:;::......rj...m.rfrj.'.\\//!tt/\ti'.r!t\it/!:/::\i\$/ri\}:::}tf::i, Date of Death or Period to be Covered by Search t;;! HCS ;} - ) g .- 1 \ Social Security Number of Deceased Name of Deceased First Middle Maiden Name of Mother of Deceased Last Y<35..- ~g - '-i 0'10 Date of Birth of Deceased Age at Death First Middle Last Place of Death /09 4 ~f7 -I- () -r J. I r IS \-\ k. ILL. /1/\1 Name of Hos ital or Street Address l Purpose for Which Record is Required Month Da Year J:2.-SJ...~ Villa e, Town or Ci Coun .D~,v I fJ L What was your relationship to the deceased? E 'f,. - S f"o J S; e In what capacity are you acting? 5e L. IF- I bQl1e~lclMi If attorney, name and relationship of your client to deceased Signature of Applicant ,p ~ 0. . ~ Address of Applicant 0 ~. ~ --L- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death MAR 2 8 2011 'n" nn ... :,.:'.:'.?::{:.rpUE4$E:RBIN1UtlAME#~NDt:.:.. Name f (' \J $ e Aft I A.L ) vV 5 I C l) . Address 30 5c. r ~!IITO tJ 0 FFI (. E City 5, (. ?. r/t tiff () w ) f ~R 'I:.. State f,q . Zip Code I~SO ')- /?g DOH-294A (6/2000) Q (v ~(\ll f\1., (l.d"\ rll-tI\\ e./Y"t ~ 0 C"bDI 5Lt ~O "5 Gf(A.f'l\01\ ( ~A \ ~S oS Prudential Retirement The Prudential Insurance Company of America 30 Scranton Office Park Scranton, PA 18507-1189 1-877 -PLN-4MTA www.retirement.llrudential.com ~ Prudential .....,.. Patricia Luhcs 602 Meadowridge Circle Beacon, NY 12508 Plan Number: 006186 Sub-Plan: 001690 Reference Number: 00618684070 Decedent's Name: Mark A Luhcs 5<;1\ L.MI '-f =- LlorO March 15, 2011 Dear Ms. Luhcs: We have been informed about the death of your ex-spouse. Please accept our sincere condolences for your loss. My goal is to make the processing of your request for death benefits as prompt and convenient for you as possible. Our records indicate you are the sole beneficiary for the account referenced above. As the beneficiary of this account, there are special rules that apply to your receipt of a distribution from this account. Penalties may be incurred if the account is not distributed within the timing standards set by the Internal Revenue Service. As a beneficiary, you have the same rights as a participant with respect to annuity options and making exchanges between investment accounts. If you would like a prospectus or related materials, please call us at our toll-free number. At this time, I would appreciate your help in providing the following so we can process this claim: . In order to process a disbursement, select an annuity, or set up a separate account in your name, we need an original or certified copy of the death certificate. If the cause of death is listed as 'Pending Investigation' or 'Undetermined' it will not be accepted. Prudential will require an amended death certificate that indicates natural causes, accident or suicide for reason of death, or a police report stating that the beneficiary is not a suspect in the death of the decedent. I've enclosed a form you may complete and return to us in order to have your portion transferred to a separate account under your name and Social Security number or paid in a single sum. If you elect to set up a separate account in your name, please complete the Beneficiary Designation Form. You may request a disbursement at any time in addition to the required minimum distribution (if applicable). It is our understanding that any funds paid to you should be reported as ordinary income for federal income tax purposes for the year in which the funds are received. You may wish to consult with your legal or tax advisor if you have any questions regarding the tax treatment of any payment, as Prudential Retirement cannot offer legal or tax advice. i' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record PLEAse COMPLETE FORM AMD:ENClOSEFEE .. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Michele "Mike" Saraceno First Middle Name of Father of Deceased Donato Saraceno First Middle Maiden Name of Mother of Deceased Angela Ventre First Middle Place of Death 7 Dwyer Lane Name of Hos ital or Street Address Purpose for Which Record is Required PLEASE PRINT OR TYPE Date of Death or Period to be Covered by Search March 17, 2011 Last Social Security Number of Deceased Last 094 42 6938 Date of Birth of Deceased August 2, 1930 Month Da Year Age at Death Last 80 Town of Wappinger Villa e, Town or Ci What was your relationship to the deceased? In what capacity are you acting? Funeral Director If attorney. name and relali~ yo<Ir Client~ Signature of Applicant l ~l ~ Address of Applicant 895 Route 82 Hopewell Junction Date 3/ir/(f NY cOM ~ Number of copies requested with confidential cause of death V1198a .. _ Number of copies requested without confidential cause of death PLEASE PRINT NAMEA. o ADDRESS . SH()ULDSeSE . Name Address City State Zip Code DOH-294A (6/2000) .'AtilltEBCL..... NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased "'5~ ~1jU"' () First Middle Name of Father of Deceased ~C>l, Last ." .. ..' . .' . :~:;;.:,., .: ;:~;..: . : :;:: :::: :; ;.;. Date of Death or Period to be Covered by Search illl~/IO Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last First Place of Death Middle Last Date of Birth of Deceased UZ; 01 Month Da WA ('VIt-.J6tf2 rJ0! Age at Death 40 Year ~t.{ -Cv 0 \-J\ Name of Hos ital or Street Address Purpose for Which Record is Required D..,fL~ Coon ~;" )C ""+ What was your re\ationship to the deceased? no" L In what capacity are you acting? If attorney, name and relationship of our client to deceased Signature of Applicant /" Address of App\icant Dat~j~} {I J _ Number of copies requested with confid~ntial cause of death ~ ') ~ . _ Number of copies requested without confidential cause of ~C;;~. . 72eJlULc '/I c;J ~.. Of\f . .;:;.;.:.; Name Address City MAR 01 Lull TOWN OF vV APPINGER TOWN CLERK 00.< H:-?~... (6/2000) /61 V NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ;;;E8Qt.OE:'EEe::u::;::)) -:.:<<.;.;.:.;::-:.;.:.:.;.;.:.:-:-:;.-;-:.;.;.;..,,-;.;.;.:-:-:-:.:.: ...... ...::::':';:;:::::::::::::::-:::::::;:::::::;:::;:;:;:::::::.:;:::::::::::<:>:::::;:.: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ' r(~{\2x '\C K 0 a.. \J \ c\ First Middle Name of Father of Deceased C \c{j.r~ V\CL- First Middle Maiden Name of Mother of Deceased Koi'V\'\~ Last ,::: J ..:' '::::.:.., -.:;::::. Date of Death or Period to be Covered by Search ~111~clo Kc\'V\ \,~ Last Social Security Number of Deceased Date of Birth of Deceased Age at Death First Middle Place of Death ~ I _ I \ 0 ,qe.. ~.QJ/\~ Name of Hos ital or Street Address Purpose for Which Record is Required FDx ~)O'(\ ctr\d d tltL5h+ ~\('i ("e~u. e5 ~ What was your relationship to the deceased? d (1 1.A'3Vl+e.. ,,' In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicanl cjaM-l~ I / ~) I1A. J..--, Address of Applicant Last Month Da Year to ~ pi (\C{e \' f(A.\ \0 Vida e, -rown or Ci OLCfc he.s S Coon kJ~ A 110'( (le,~: DiaMond Date J, I J-~~ I J-O /J ., .... ." a2- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) :J:::t I 0 VETERANS SERVICE AGENCY Anthony Zippo Director 111 Cnigville Road Goshen, New York 10914 TEL: (845) 191-1470 FAX: (845) 191-1558 Edward A. Diana county becutive February 16, 2011 Town Clerk Town Hall 20 Middlebush Road Box 324 wappingers Falls, NY 12590 Re: Ignatius paolino (veteran) Please furnish a GRATIS copy of the following record which is required by the U.S. Department of veterans' Affairs (VA) in support of a claim being developed by this Agency. The document MUST bear the ~ of the issuing office. ( ) ( ) (XXX) ( ) ( ) Military Separation Record Marriage License and Certification of Marriage Death Certificate (For VA purposes, the Death Certificate MUST show the CAUSE OF DEATH) Birth (with name of BOTH parents) Dissolution of Marriage (Certificate of Dissolution) DESCRIPTION: Rosa paolino (Vet's spouse) DOD 2-11-11 at wappingers Falls, NY A return envelope is enclosed for your convenience. Your cooperation and assistance will be greatly appreciated. Sincerely, '(\.\}". ~ ..4 ,.,:...""''''''' k U""""'::'" ,.;,>.,~ . ~\ ,,;. (, " ~ Anthony Zippo Director AZ:NZO:mm. )\'tl31'J NMO;M01. 't\39Nldd~ M :!O \\01. L \ t\3:3 rfJJ~m,~~'j~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record PLEASECOMPl.J.;TEFORMANDENCLOSEFEE ...... . . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased . .........~ch(\ Fllst .. Pl.EASEPRINT OR TYPE.. Date of Death or Period to be Covered by Search ~. Middle N\\~~h Last \="e.ea . \\, .2-ca.\\ Name of Fattler of Deceased Social Security Number of Deceased ~r\ ~~\~cV\ FII'~ " ''-1' Middle Last Maipen, Name of Mother of Dec~ M\\dyd ~Y\CeV\L Fllst Middle Last Place 01 Deatl,' . \ "'"\) \ '?i qOG ~ Name of Hos Ital or Street Address Purpose for Which Record is Reql,Jired .~ ~ L~ ~ \G\(S. --- What was your relahonship to the deceased? ~~\ \J.-=-~ In what capacity are you acting? q(\ ~.. & ~ If attorney. name and relationship of your client to deceased .-..J Signature of Applicant ~ . ~ ~ Date Address of Apphcant fb ~_ 16(/ ~r~\\'>" ~'f Ob7b - 2ce ~ yCj 9-\ Date of Birth of Deceased ~ \'-\. \C\~ , Year Age at Death =fB ~\t~ County 2- \y-,\ \2~ () .,.' ............, .......,.... .".....-....,......'........,."..".' ...,- ,............,........,.."...-.. ..-..,........, COMPLETE. FOR DEATHSOCClJ HRINGAS OF JANUARVH 1988> ..... umber of copies requested with confidential cause of death [Ri~(C~~~~[Q) Number of copies requested without confidential caLise of death ...>PLEASEPRI Nt NAME ANb AOORES$ WHEREReC Name. Address City _______ State Zip Code / (\~ ~\:.- IJOH-294A (6/20~O) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Copy of Death Record '.. .., """PCI$AseCbMPLETEFORM AND "ENCLoSe:PEE<'.,., ......, .... .......... ...... '.'. . ". "'" " ... ......;',.:,.. .......::....:\... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased DO'{)\\(\\C ~. ?~C>>- First Middle Last Name of Father 01 Deceased D. h..a ?~. \{)\(G\vuJ F. ,-~ First Middle Last Maiden Name of Mother of Deceased 3(LP-iJ~ --j, ~~ 'hr'St { Middle Last Place 01 Death . \ lt~ ~\rG Name of Hos )ital or Street Address Purpose tor Which Record is Required ~~~ .~~ Date of Death or Period to be Covered by Search 4. \~-~l \ Social Security Number of Deceased Ole, - (RCo' ~ ~o ~ Age at Death 30 -:PLLh~s Date of Birth of Deceased I" tYD-(CJ5t Month Da Year COLlnt What was your relatio.n~hip to the deceased? ~~ J..{(~ In what capacity are you acting? 1M. \De1toJ.~ of ~\l1 If attorney, name and :a~i~ns~iPOf~ceased Signature of APPlica~ Date' t' Address of Applicant SS e. ~ <;taA-) ~1g ~. ~ I~ () . . ..,...,.... COMPLETE FOR DEA THS''ObCtiRRINGASOFJAN . An"yH'::i9aa::::::::-::::':=::'::::::-:::":':':-:': ..... ...,........ ,..... ..' ..............." ....">,......,.. -3- Number of copies requested with confidential cause of death ~ Number of copies requested without confidential cause of death r;;:;:.. . i {/5) re (1' ':. I lJ"li Ls; "C PCeASEj~RINTNAMe'ANp:ApD.RI$$S:WHEReR .... 1 4 20U . 'J;;'-;;$Ho\i' 1"" C Name ______ Address City ____ State Zip Code DOI-l-294A (6/2000\ NEW YORK STATE DEPARTf'v'ENT OF HEALTH Vital Records Section ,-- Application to Local R,egistrar for COe)' of Death Record PLEASECOMPLETEFORM..ANDENCLOSEFEE FEE: $10.00 per copy or No RecorCi CE~rtification. Please do not send cash or stamps. I PL! Name of Deceased L"itJrJ A- ])E F~u C. First Middle Last Name of Father of DeceasEld _JEt2.ey De:p~L First Middle Last Maiden Name of Mothm of Deceased ANC&Lf} CR./S TrNZ First Middle L.as t Place of Death /t,t q tCou T € q 11r'T. /'-fC I Namp of H()c;ritat or Street Addn~ss Purpose for Which Record is Required What was your relationship to the deceased? _ In what capacity are you acting') ____ ~A If attorney, name and relationship of your client to Signature of Applicant "7- ./ ' (..t. ;/)p j~ i-'.AJ..J_ Address of Applicant _~~~---1MA1fl_--5J-,- COM.PLETE ..FORDEATHS.OCCURRING...AS...OF.JANUARY.1 1.968 r:: PRINTORTYPE ... ..... ........ Date of Death or Period to be Covered by Search /1fJfi? . /3, ::lc / I Social Security Number of Deceased 69,- - 5'1-- 2 '-'7/ Date of Birth of Deceased Age at Death , 8' !'l~O .50 Month Day Year IN 11-1'1'/ tJC.ER Pu TCft6<; V~ Town or~ County k1?4C- 7) 10 E?TOJ<- - -- Ised Date ~-IS--II //VG€I?S P-r:; 1 L <:; _ IIf 'f J 2.5'96 - :ASE ICe I!NO J:Y.JJL ~~_. decec ~ WE. ..... ~. Number of copiE~s requested with confidential cause of death I ~\r~'lLU '\ __ Number of copies requested without confidl~ntial cause of death "PLEAse..'PRI.NTNAME..AN[yAOlDHE$SWHERE RECORD Sl-fOUL.D BE. SENT.... Name Address , --_.._~--_._------------ Zip Code Cit State y -~---------_.__._--- DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coe.y of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name 9l Deceased ,t'tlT/f First Middle Name of Father of Deceased A/t:JC/c sElf 3~~oC!J( First / Middle Last Maiden Name of Mother of Deceased _ V (21f1the lO T r E r/E1'fL. E/ First Middle Last $A'/Ii?/VE Last Date of Death or Period to be Covered by Search ~. y.,l,OII Social Security Number of Deceased Ofr'o - 't~- rl.. " Date of Birth of Deceased 05""' 01- /9~1 Month Da Year Age at Death &~ Place of D~th r~ IVEW /#te~E#S/fcK /d. #/~ Name of Has ita I or Street Address Purpose for Which Record is Required ~/~ W,q./;?/AI~E~S Villa e, Town or Ci 'D UTt!HESS Coun What was your relationship to the deceased? In what capacity are you acting? PI:> If attorney, name and rela' ns ip of your client to decease Signature of Applicant Address of Applicant ;::'::'liQMPtETEFOR'oe.THs]jec.uARINGAS;:. ~Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of de th JUN 1 0 2011 TOVliN :) " , I VI(flt C'j 1= .;:::,:::')ec.~$~:palNT::N4M~:ANQ'lM)DRE$$:VlA$aSBe~RQ$aQ'i.1/- I Name Address City State Zip Code DOH-294A ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record ".. - -, "... ......;.;.:.:.:-:.;.:.:.:.;.;.:.:.;.:.:.;.:.:.:.:.:.:.;.,.,.:.::.:.:.;.:.;.: .........-.:...;.:-:-:.:-:-:-:<.:-:-:.:.:->:.;.:.;.:,,'....:.:.......:-:.,.:.>..-:.-:.; ........... ,,-.. ..... .... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. r(lvZ ;:::<. .1.: ,{.. Date of Death or Period to be Covered by Search Co~r (rJ01/ Social Security Number of Deceased a;)- 4(-:ff10 Name of Deceased Lu ,IlI'A- ~ First Middle Name of Father of Deceased WA-IJ-ut ' First Middle Last M.iden,%~ Mother of Dece..eM~ Dale of jrlh of)7 I'/r-( First Middle Last Month Da Year Place of Deathi'\ L S /'" .. .,..... ^ It-- D -' WAcD L)l;,r c... '\ e 5 '-U\..))-(V \ '1. . ,,. \ f '- r z>>'V \ I 'If -ttv'bvz, ~ Name of Has ital or Street Address Villa e, Town or Ci Pu~se for ~~ ReL~~:\ 1< I V 2- Last Age at Death 60 . \JJ~C.5 5 Coun Signature of Applicant Address of Applicant '3 I I/I~/II ~~ ' Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death City tI!'I:l::u:a;UI!::,:a;:ug<,: :.... g:=-:::..~ .:Mf'!II .",.. .. ~__~'--'::"i' ","C' C'~-:c.'~\ ...__.'.....__.,. _) i......,.'. .'J. ..--.~ . ._.,~ '. -; .-"' : .' , . ~_'. '. . , . . ,_.' . " . ',no_' d"-' ,.- .,.'. ",,' ,\ ,'. ' \ \;. \ ,., r. '\ \ j\jNS~ r..\J \ 1 \ " ............ . .... .. Name Address DOH-294A (6/2000) i \ I l~::-:.P \ \ .,---' Zip Code Edward F. Carter Funeral Home r--" I I I I -------; I JUN 1 6 lull '=R I I . '''-_..-_~_l Town of Wappingers Falls 20 Middk'husr. Rd. Wappingers Falls, NY 12590 06/15/2011 RE: ALICE CORREA DATE OF DEATH: 06/11/2011 Our Funeral Home recently filed for the above Mrs. Correa. We are requesting 4 additional transcripts. They can be mailed to the Informant. If you have any questions, please call our office at any time. Thank you Edward F. Carter Funeral Home 170 Kings Ferry Road. Montrose, NY 10548. 914-737-0900. Fax 914-737-8312 41 Grand Street · Croton-on-Hudson. NY 10520 . 914-271-4882 DignityMemorial.com NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section - "-'_I_i.I~-.J t__JI_I~1 Application to Local Registrar for COe.>' of Death Record --- i.PLEAse...COMI:)We:WI2..PORIVl....ANP..ENCLOSEFES.................. . FEE:: $10.00 per copy or No l=iecorc CE.rtification. Please do not send cash or stamps. Name ot Deceased 1/ LI c.f First Middle Name of Father at Dec3ased FIZ&lJEa fG/.! First Middle Maiden Name ot MothE"- of Deceased ;M, f!}12 t 5WAN,44f/flJ First Middle Last Place ot Death ,3 (, ~~ ~ ~R.T L/-JttlE Name of Hospital or Sf-eet ,c\dd~(?ss Purpose for Which Record is RI?quin:1d Col2tt.€1I I_ast Date of Death or Period to be Covered by Search ,-/(- If Social Security Number of Deceased c~ UScNS Last /;)'1- ::/9- (,'37 Date of Birth of Deceased 6GI- 30. Month Day / '13'- Year Age at Death r,'-{ WIJP~/I>I&-{;e. ~, Town o~ .DUTCJ.jF~~ County () S€7Tt..~_I%5.IE.IJ::- __.____ What was your relationship 10 tl1(:1 deceased? FutJlE/U/L [) IlZec..7C> ~ In what capacity are you acting') --____:::?.!7_f'!'1 ~ If attorney, name and r3lationshi.o of your client to deceased Signature of Applicant ~ tl. ~..Jl.~ Date "-/~ II Address of Applicant _-..k!ig_/I1_Iil.ALS~--0)~!!!"~&EI2~ P,<:JL.LS "'..../ I ?c:;:-qo , ..................................(;ONrpLE1-S.F:oi30E:ATl-lSOCiCORRINGASQFJANUARyj 198.S\....................... ;:)../- Number of copies reque:3:ed with co Tfident al cause of death - Number of copies reque:3ted without confid :1ntlal cause 0 deatlR< iF (f~) tJ b ,.,,-,' r; :/ . --,_.__.--!-_._._._..~_.__. Name Address City State Zip Code /~-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coer of Death Record ::.'..:..:~18EA$e.~QMPJil$mEFQ.:SMANPENe4~r;.flEE)' .....'..............................................,............-,...................-:<....-:.... .._..-...........................~.......~.. .. . ...-..... ..-...................... ....... ".-,.- .............. ......... ......-...-. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased VEA.'NON ~ First Middle Name of Father of Deceased ~.mntlE'- L. First Middle Maiden Name of Mother of Deceased If1AY First Place of Death /7' aJE6 r ..::5 r. Name of Has ital or Street Address Purpose for Which Record is Required WAy Last Date of Death or Period to be Covered by Search ~,Z1' 'Z-Oll t))Af Last Social Security Number of Deceased of'i. Zo. BCjS-1 Middle rzEMIN~ Last Date of Birth of Deceased 1'2- 02- 19z7 Month Da Year Age at Death 83 WA f>,P/AI~~ A. S FA~t. S Villa e, 'DIJT~~SS Count r .1ffl'1/t" Y #EQ:>5 What was your relationship to the deceased? In what capacity are you acting? rD If attorney, name and relati rD Signature of Applicant Address of Applicant Date ~ h~h.o" 2~oi I :'.::::COMRuereFofi'f.:[)EATHS:OCCURRfNGASQF\JANUARY11ij88:::/:>',. 1 /~ Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death fC;I. If')< n'iI 11 r;= T] d\'1 IS/I) ',' </ I_~ e:-' ........_--.......... ;;;;::::::::;:::::;:.:::.:;:::;:;:;:::::::::;:::;:;: Name Address City .JC'IJ\iGER ; S\; '-K'.'} k' >.- -,,'.'~._.._~~~~__ t State Zip Code DOH-294A (6/2000) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record .. '........... ................... ................................p. ':::E:A:S..' . . ~~?).??t???~~???)<: :,~;~ .: t.';' .', .: ... ..-.... .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Na'{lte of Dec~ased \ . UO'm\,^ \ L- AV'\"t-'-\MJ First Middle Name of Father of Deceased Last {:.,... : :t...:. Date of Death or Period to be Covered by Search t-f 1(2--1 JI Social Security Number of Deceased First Middle M~n Name of Mother of Deceased J 0 5-t. {> h,.....<..., First Middle Place of Death l\ I L~'k e- \)"1.- Name of Hos ita! or Street Address Purpose for Which Record is Required Last Q~pe ') CPo [est Datr of Bi7 ol~ceas/ed '6 J Month Da Year Age at Death "'30 WP\~P!:N~ Villa e, Town or Ci OvklwJ Coon What was your relationship to the deceased? In what capacity are you acting? ::::(1"\\1,")' ~-'t- \-) -t. 'tV'ISP If attorney, name and relations of your client to deceased -..../ / Signature of Applicant Address of Applicant Date G( 7-6 ( [, ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City --- Stat tR\ IS, 1; [E~ jl'\.i7 :[~ifC900e DOH-294A (6/2000) NEW YORK STATE DEPAf1TMENT OF HEALTH Vital Recol-ds Section - - .__..-... ---11_-.11- <PLEASE:....COMI::~LEIl~lt..FORM..AND..EN.C.LO$EFEE...................... Application to Local Registrar for COe.)' of Death Record FEE: $10.00 per 80Py or No Flecorc CErtification. Please do not send cash or stamps. .... .<......>..>...................<<.... ............. ...........U<....b(5M.P[El'Ef:'(:>RDe:ATHS .OC:CURRINGASOFJANUARY119Sa.....HY/......................... ... ... . -t"\ ~- Number of copies requesTed with co Tfident al cause of death Name of Deceased J6S~PH l2. First Middle Name of Father of Dec:lased JA Me-S First Middle Maiden Name of Mothl,r of Deceased JULIA First Middle Place of Death LAY'FrN Avi..:! BvR.1< Last (3uRw Last "b~NNEO Last Na~~f r.l@iitpital or St-eet Addq,ss Purpose for Which Record is RGquimd /0 ~6}T~ ~~AI'; _____ What was your relationship to tl113 deceasecl?_--E In what capacity are you acting') ______ If attorney, name and r31ationshio of your client to Signature of Applicant _~ a.~ Address of Applicant ~--E...~...M..~2L ... Date of Death or Period to be Covered by Search ~ ~- 5- ~Ol( Social Security Number of Deceased t:. / 3:2- 1'g-<151?(, .--.- Date of Birth of Deceased Age at Death \./ 9 :)f, /'f:J.? ~3 Month Day Year .---- WA"flrJt;~ICS FRI.-L.S Durclt€$<: Village, T<8V~Tl or City County ._-- '--- ~~_~f?AL D.e. - 5 A- ~"'1 IE deceased ~:7J Date '-G,-f( ~&t:fC~ FAl,t...$ NY 125'10 - Number of copiHs requested without confid :mtlal cause of death ... . ... .. ......... .~~iE8BI~INTNAMJ;.ANPAOI'R-Et$$WHf2BgRf$P.PFHJ).$HQQ.U[)~ElS<SgNJr>>...... ... Name Address City . .--!-.-.----..--.--. DOH-294A (6/2000) State Zip Code r II NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Cae.>' of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: 510.00 per copy or No Record Certification. Please do not send cash or stamps. Last PLEASE PRINT OR TYPE Date of Death or Period to be Covered by Search 5/::21/11 Social Security Number of Deceased d f> 1- '/& - OPOP Date of Birth of Deceased Age at Death MZth / ty )-~I: Ie; d- WAIJ'A.f0v jl.~ tJAJ/'~ County Na7?4 t;;a~; ~ L. First Middle Name cAFather of Dece<}ped ~ ~ I'K.II\rC/ First Middle Last Malden. Narrr of Mother of Decease.d /). J/ II UtdJ j/c-l r i " First Middle Last Place of Death So ~/VJO IV /(Uq (t Name of Hospital or Street Address Purpose for Which Record is Required {'g What was your relationship to the de~ed? I' 'LJ In what capacity are you acting? J V If attorney. name and relations ip of your client to deceased ;' Signature of Applicant Address of Applicant :~ ~! PLEASE PRINT NAME AND ADDRESS GQHO,$HOUL(} J3E E T f. i <~ 1.'.: L... ~ TOVVN C K Name Address City State Zip Code ~/Vl OOH-~~A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record .----.....-...,.........-......."...... ...... ..........__. __d .n.... d, ..-.....-......................'.'...... . - . . . . - - - . . . - . . . . . . . . . . . . . . - . . . .' .... ...................-....-...-.......... .....-.--.-........................... ....... - -.... .............. .... -.. -.... .......----......................-.... ...........-..-......................... ................................... .. ...... .......... .... ::~P:cEA$:e:$QMpp1s.m$:eO':RM\~NQ.ENQuQ$eFsE .....-.......................,..........-- .............. ............................ ........................... ............................-......,...............,..... ..............-..-.....................................- ......................................................... . . . . . . . . . . . . . . . - . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................,................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... ..........-..........-............ ... ................. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased f}< A ,.j C!t:S C, First Middle Name of Father of Deceased u.> I ~(.., A tyl a. fl4< ~ "-S' 0 tJ First Middle Maiden Name of Mother of Deceased A~~A mA'I HIC.[,(l First Middle Last Place of Death I l'-f tJe ~ H A-1'7 i3u t~ Qo\ Name of Hos ital or Street Address Purpose for Which Record is Required GA K\<.\,s c J Last Date of Death or Period to be Covered by Search \$'- J'L - 1.0/1 Social Security Number of Deceased Last 0'12..- A.l.f - J 2..'-0 Date of Birth of Deceased Age at Death , Month ~,., Da IC, 3 I Year ~() D t..cr c. k s.r Coun r: IJ yt11 '- ... l'-.l t::" C 1> S P. V What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relaf ship s-h) I _()~ Signature of Applicant Address of Applicant ::~:..:CQMBliliET.:E.FOR::jjE:THS:ObcuRitNGA~:f.QE:ijANuARM119aa::): ~ Number of copies requested with confidential cause of death ............... . ................. ................. . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................-.......... ................. _ Number of copies requested without confidential cause of death :::::~~~::eueA$~:aB.JRt~NAMeA"I~UQR~$$~Ml8$a:e::B$m>R[:)$HQQep.l;JE$eNT: ....-..... .....'..- - -.... --,.,. .... ... .......... ......... ... -....................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......-..........-....... .................... .................. Name Address City State Zip Code DOH-294A (6/2000) .. May, 18, 2011 10:20AM No,1503 p, 2 III I -B ! a Dutchess County Department of Mental Hygiene William R. Stelnbaus Courtly EX.~Clllive Keuueth M. Glatt, Pb.D. Commissiom:r 230 North Road Poughkeep~ie New York 12601 (845) 485-9700 Fax (S45) 485-2759 May 18,2011 Office of Town Clerk Town of Wappingers Falls 20 Middlebush Road Wappingers Falls. NY 12590 RE: Name: DOD: DOD: Residing At: Donald Cvijanovich 05/31/1963 09/22/2010 103 Simone Drive Poughkeepsie, NY 12603 Dear Sir or Madam: The Dutchess County Department of Mental Hygiene, in accordance with Section 45.19 of the Mental Hygiene Law which requires the reporting of all deaths of persons living in mental hygiene institutions and facilities with operating certificates from the Office of Mental Health. is investigating the death of a patient registered with this Department. In order to complete the investigation-and reporting of the death of the above named individual, would you please send me a copy of the death certificate at your earliest convenience. Thank you for your cooperation. ~ [E (G; [E ~ %7 [E [Q) 280MH RBVl1110 RDEATHCR MAY 1 8 2011 TOWN OF WAPPINGER TO\NN CLERK -tf~'11 lei 0 ~ May, 18. 2011 10:20AM No,1503 P. 1 Dutchess County Department of Mental Hygiene William R. Sleillhaus COUllty Executive Kenneth M. Glatt, Pb.)). Commissioner 230 Nonh Road Poughkeepsie New York 12601 (845") 485.9700 Fax (845) 485-2759 Office of PSYChiatric Services Fax: (845) 486-3745 Betsy Fratz, RN Nursing Supervisor (845) 486-2892 Richard Miller, MD Medical Director (845) 486.2780 This transmission is intended only for the individual or entity 10 Which it is addressed and may contain inforrnation that is privileged, confidential, and exempt from disclcsure under applicable Federal and Stale laws, This information may have been disclosed to you from records protected by Federal confldentlality rules (42 CFR Par1 2 and Health Insurance Portability and Accountablllly Aot (HIPAA)]. TI'1e Federal rules prohibIt you from making any further dlsolosure of this information unless further disclosure Is expressly permilled by the written consent 01 the person to whom It pertains or as otherwise permitted by 42 CFA Part 2 and/or HIPAA. A general authorization for lhe releaSe of medical or other information Is NOT suKlclent for thiS purpoSg, The Fgderal rules restrict any use of this infOrmation to criminally investigate or prosecute any alcohol or drug abuse patient. If the rearier of thIs communication is not the intended recipient, or Its employee Or agent responsiblg for delivering communication to the intended recipient, you are notified that any dissemination, distribution, or copying 01 this communication is strictly prohibited. If you have received this communication In error. please notify the sender immediately at the telephone number listed above and return the original communication 10 us at Ihe above address by U,S. Postal Service. Thank you. Fax Memo To: FromTi ~ ~'" j( if Pages: ~ (Including this page) Ohn'S Jq f - ILl!?: 5Ll fUJ ~ [}alil. &.(} ~, Coc;;;;,:KS -Arr rpv Ik1p / Fax: Date: Re: cc: NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local ,Registrar for Co8.Y of Death Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................ . ............................ ... .....-............................ . :F:nJ;J.~$~aiPMe4e.t$:eOAMA8p.ENQCOSs.::~ee/\\ . ?" ............. ..... '.0. n ....................... ...................... . . . . . . . . . . . . . . . .. . ::: :~~~j;:jj~:[ j: ~ jjjm~m:~ j~j~\ ~ j ~: [:\: ~j\:~ j \;jj] :j~:~::j . ............. . ....... ..........-................. ........ .-.............. ......-......... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of '(,ceased \.f\0\~\\ 0 ~ Firsl Mtddle Name of Father of Deceased c,H.o1~ Last J;:,'PBIIOtQS:11lPE:::? ...., '.,'" "".. d' ".. Date of Death or Period to be Covered by Search CS{ 0'11 , J ................. .. . - . . . . , . . . - . . . . . . . . . . .. .......... -........ . ..................- ..................... . . . . . . . . . . . . , . - . . . . Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last First Middle Place of Death r ~C> ~~~ ~\\c.'\..r~ Name of Hosoital'Or S\r;; ~ddress Purpose for Which Record is Required Last Date of Birth of Deceased 03 P-f ~ 4 Month Da Year Age at Death 77 ~~~Q.$5 Coun "\ What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relatio ip of you Signature of APP~. Address of Applicant :):::::f:::rr:'t)m:f:r:::')::):::::mmt::)'j):::'):fff::::t:)if:.;:::,:::,:;:.:::,:,:,:'::';':t":;;.:,:,:,:.:,:(,:::::,:::,:::.:::,::t:':'::"';':i'>:;:':t",:",;::.::)t:;.:::.;;:::;,;::,:,;,:::,:,:.:.:.:,,::.::;,:,;,:':':':"'::::r:':::s.:?~::':':'::;:r';':;:':"(::"::t:,:,:,:,:':::';:':::;::r:}{::'::::':':::':':':':'}::):ff:'))::::fft)))::'f:t:::)r:ff)::rr::r:)'ffm::::rrmf::):):::':::f ~. Number of copies requested with confidential cause of death _ Number of copies requested without c()nfidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. PLEASE PRINT OR TYPE Name of Deceased Date of Death or Period to be covered by Search Mary Eggleston June 27, 2011 First Middle Last Name of Father of Deceased Social Security Number of Deceased Paul Cignarale 081-16-3978 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Carmela 9 5 1918 92 First Middle Last Month Day Year Place of Death 184 Osborne Hill Road, Fishkill Wappinger Dutchess Name of Hospital or Street Address Village, Town or City County Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement ofthe deceased What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Date June 28, 2011 Address of Applicant 1028 Main Street, Fishkill, NY 12524 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 5 Number of copies requested with confidential cause of death Name Address City State Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD DOH-294A (6/2000) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.}' of Death Record . . "PLEASECOMpLETEFORM ANOENC.Lose>FEE.....i ...... ........... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ ..-tNard V\J,n.{)i~d 13\c:t-t2..- Fllst Middle Name of Father of Deceased WI (\ -P-i ~c-l <S; First Middle Maiden Name of Mother of Deceased EI'Y'I~ ~or~~ First Middle Last Place 01 Death L.( RIA"2E. ~C-e- Name of Has ital or Street Address Purpose for Which Record is Required _ . ~d &LI~ . ..... .....d>pLeAsEPRINTOR Date of Death or Period to be Covered by Search Last Cc> - \ (0- \ \ Social Security Number of Deceased f2:. \"" -tz. Last I \ 0- '30- '::J 8>2 Date of Birth of Deceased \2-(0- ~ Da Age at Death -=[-2... Month Year '~..,dL-~S:. Count A~\lIS. What was your relationship to the deceased? ~V\e.J.b'-\ 'D ~ r<:.c.....~ In what capacity are you acting? ~ ~o..l+' c.-P '~..-n \ ~ If attorney, name ~nshiP o~ your client to deceased . _~_. ~ ~ ~ c.9--I-=t -1\ Signature of Applicant . Date Address of Applicant 'Th ~ ,~, OL t'?' ~~ ~ ll~" ~i (2910 t' l~ ..' ........COMPLETE FOR DEATHSbcdURRiNG . .. . '.. - . - . . . . . . .. ,.. . .. '.. ".'.". .-..... ..... 8 umber of copies requested with confidential cause of de th ___ Number of copies requested without confidential cause of TO\l\lN .. ..............::RtE;ASE'Ff~IN't.NAMe<ANtfA[)ORE$$WH. .RER .. . Name Address City ____ State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record PLEAseOOM'LETEFORMANDEMCLOSEFEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. pt,;;EASEPRIMTOR TYPE Name of Deceased Date of Death or Period to be Covered by Search Kathleen Marie Haw First Middle Last June 2, 2011 Name of Father of Deceased Social Security Number of Deceased Patrick Walsh 062704136 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Theresa Thornby February 12, 1970 First Middle Last Month Dav Year 41 Place of Death 190 Shale Drive Wappinger Dutchess Name of Hospital or Street Address Villaae. Town or Citv County Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? Funeral Home <<attorney, name and 'elaM: 01 your cl;ent to deceased { f3/11 Signature 01 Applicant \. ~ .LA ~ Date Address of Applicant 895 Route 82 Hopewell Junction / NY eO,f ' . .9-0F ~ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PL ... .SEPAINTMAMeAN . ,ADDRESS WHE SHOULD BE Name Address City JUL kl6 2011 Zip C e !\JGER T(~ ( r= [;{ IK ~_~.~:~__ _ _~_ _ ~.:~~:.ti \. " DOH-294A (6/2000) McHOUL FUNERAL HOME, INC. 895 Route 82 Hopewell Junction, New York 12533 (845) 221-2000 JUN 1 6 2['1 To,n'.' . V\j ~\j - '- REQUEST FOR CERTIFIED COpy OF DEATH CERTIFICATE Number of Copies Date Ordered rR ~ct\(1vcl ~ '--1/:3/11 ~//Lj/" Cost County ~ (00 ... / ---bYl Name of Deceased Date of Death Ordered By Remarks w~ Copies Are ReadyA MAIL TO 0 DELIVER TO Name UlYl) \ "-1 V\ f\Q S+t o;v Address C;?' \ Clov(L <1SV7JA'\.r ^- ~ ::}j- D HOLD FOR D CALL Phone City and State LS'3'J Zip NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record . -.....":.....;.:.:.;.:.:.>:-:<-:-:.:-:.:.:.:-:-:::.:-:.;.:< ....................:-:...:...:....:.....-. :Pt4A~$:$~,oqMeJ;is'tf$JlQaM:~NQ:;NQU~$:s5Egn~::HH FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased c.~rlottlL L. First Middle Name of Father of Deceased CL.ftu.)) E First Middle Maiden Name of Mg!I1er of Deceased ~uc,LLC ?O~D First Middle Place of Death X. W _ "l f. '- A,J-I ~ liPPlrv,er Name of Hos ital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search 1(,( by Last ~"'/~'20 II Social Security Number of Deceased (319 'R tJ 4 IV) Last Last o If 't - '2.1..- frJ " ? 7 Date of Birth of Deceased I ~ 0>3 I CfZ-' Month Da Year Age at Death ~1 Fa.l(s i>kT~ Count f~m' L Y N t:.-t7)f What was your relationship to the deceased? F. 1). In what capacity are you acting? r: D If attorney, name and relatio Signature of Applicant Address of Applicant Date J ZrcJ1/' f::,- (,,- ~() II ....}::.}}...:....:......:....>..COMPI1.iEEOA.bEATAsbCdUaRINGASOt#MANUiRMH19SS/....<.<>>......:>............................. L Number of copies requested with confidential cause of death . .. .... ........ ........ ......-:::::::::::::::::-:-:::.:::::::::::::::::: :H:/PU~$$~P$IBl;:Jtge.A.:NO..QRS$~hW...f$. . ..... _ Number of copies requested without confidential cause of de Name Address City State DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record . . ':PL..EASECOMPLETEFORM ANOENCI."OSEFEE..>.... . ' , '. '. '. .' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .. .. ...-. .". '.' ." ........... ,-, .' - -"- .... .... ......PLEASEPRINT OR TYPE::<'::' . .... Date of Death or Period to be Covered by Search Nam~::r \f\l;~\~ Fllst Middle Name of Father of Deceased WY\~ld First Middle Last Maid~Name of Mother of Deceas:d , E::vnl'Y'P\. "-1 or Ka.IA+ First Middle Last Place of Death y "R'~ "RAGe- Name at Has ital or Street Address Purpose for Which Record is Required B~ Last Co. - l& - \ I B~\Z- Social Security Number of Deceased I \ C>~ CO~ TrD""2- Date of Birth of Deceased 1'2-- 1.4 - aeo Da Year Age at Death j-2- Month ~ Count ~ of- L,~ A-~~ What was your relallonship to the deceased? \-t..~ to. ~c- ~ In what capacity are you acting? CV' ~ \.r c>I;? \'VI ~ If attorney, name a tionsh' of your client to deceased Signature of Applicant Address of Applicant Date (o-2-~-\\. wt=:- , \~S;O ,.................... ..................... ...............,".. ....PLEASEp.R1NT.NAME:ANO..A,OD ..'.......... . . .................................'..........:..... ...........--. ...,...... Name Address '.' City State Zip Code D~4A (6/2000) '" NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. /" First G e r. ~ A Middle / Name of Father of Deceased 0fO/'t e Fir Middle Maiden Name of Mother of Deceased lie r ~(r'e Place of Death I. J ,j 1 ;:: // t-!AA/r w'AfJjJif'/ferJ I A/I Name of Hos ita! or Street Address f Villa e, Town or Ci Purpose for Which Record is Required /5eN/'~ ! ;//f55Cif Last cr 25' Social Security Number of Deceased Middle Date of Birth of Deceased ~~ Ji/"/L 5 /fJS Last I'T Month Da Year Age at Death If /Jt/~C te.rr Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of yo 5011/ S~I~ Signature of Applicant Address of Applicant tJ .. ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) ~ .. _-.i. ~ .J i 0- , C) , ~ ~ $) ~ ~ ~ .~ \ 10 - .~ ~ ~ ~ f l\ll:.VV y()I={I( STATt:. [)Er:'AI~rIV\i::I$r 01= I-I[AUII Vilel! HI?CU!C!', ::'''\;lctiDn ...~~ -- ~ .... '. '''~\''U'I~'''"-''''''UM_!WlfMtlI.ll!lWUlAAlIIJ.MAilIll~IIUau.l\'UWlJJIiU'.f$IIQIII~~''''''''''-l r R'eg' ~strar Appiflcat~on to LOGa . Ad for CO-EY of Death Recot r \--~---.... ---~----'-----lllL/.\Sf''CC)lVlj:~=-El~E Fcii:IIVI7.{h>1D ENCL.oSE FEE ---------. --I~ EE. ~l; I Cl 00 IJIJI 1-~)~::'~U-~ll:'l-::::~':::;~:lIUII. 1='leas8 cia nol selld cash 01' stamps, __'--0 _._~~__~_. .._..____~_~_~_..~_,_._._,~..,~_.._~.~~..n_~____._~_. . .:....:,.....: ; ,'.:".,. . ",",;.:-::..., ~~~--='7"""""---"--:-"?::-'-'--~-'~C'~-"F'I~Et0~~Ffn~INTOilTYPE .<...... ....... ." ..1~~;~I~~;r D(:1ce~\;~~;j._--~--q--._..~-'--------:._:~--: .~. ~Drlt8' 01 Dr~ElII'i 01' l:Jel'ioe! to be CoverecJ by Semch .})wltiJ-lr M- Tow.lJ$END _._.i!~!__..___..._..____ Mielclll? I_EI,;l 1\lmnu DII="1lllm. 01 D8~~~i:\sccl----'---""'-~-----'"-'-'------- SZcia! ~;8CUI'ity l\Jumber of' DecGElsecl ELf3el?r /owttlSEIli D t)SS"- 3Lf-SS"3&" J~~~__.____"_~!~C~~___._~.__~-:i220_____..___._._-__-_~" IVlcIlCI011 l\Jclll\e or IVlutlKJI DI DC;Cel:I::.8CI Dale Dr Birth 01 Deceased HELelll C!-L4Je, < // -3 --...J:i0':!.._. lV1iclclll'! LC\~~t Month Day FJlacc ul [J{~atl0-~F~.N;'~~-;-"--l>- A ;-~-;;-_.- K. Wlt'~f> //'J&e~ ~ -.;13-/1 i-f/ YGClI' Age at Death ~ <J .J)U/"CHFS~ J~2r~~~_~~ID~;PIIl:1~_~~~~.~.~~l;!L~clclrl~~':'~ ~, Town Ol~ 1:)LllpD~,l:lm Which H8COlcl is Il;(~~~;'i-'---'-'---'--'--' /0 SeTTLe e S-rA-rJ: County ....--- ~-- -~-- ~-~-- '~._--~---~~~--~-, '~'------ ~---- -~-----~---- Wildt Wi).'; YOLll18klllonsllip 10 lilt! c18cuclsecl? ____..E.t211I.€lcllJ....-.-..J>II26'"C..7lJ~ III whi.!1 CclpiJClly are you DCtillg?______~_._.--_-!2.!!.~E ___ If allollwy, IklllW clml mIEl/ioll:J1111) 1.)1 YUI.II CllCllllD CluC()(]Secl --" ----- Dlonallll" 01 APPlln,ml_~__l2._~-;;:2 DOI8_" - :1::/-1 ( ---- l\cjcllC::~"o) 01 AI)plici:llll H.~!:I~_IVJ/JI..iY._..s.Tj~-:lNl.e6JY....:-:"~A )~4.LI...5J A!~ 2-~fQ.. - ---~..~ -~- ~-'_._~-_....>~~~~....~--_._~~...-._._---_._._.__._-~--~-----.---. ._---~._..._---;-~--------_._-----_.-~~---_.._-._-_.--------_._.---_.._-_._-~-----;'- r:'::, ,:.:'."::::::<'~2:~:: -.-.--------.._2.~~ ...CO ~131:XTI~:EQB."Q.s:AIJj:G;~~~i:::UF1l~ ING).\S OF. dANUARY~ii 1;988 /D_ NUlllhul' 01 copic:~~ leC[Lll?~:;lccl wil.!1 c:unlic\{:llll:iFI: Ci~LI~;U err cleath 1\ILllnbl:!I Dr CUpll:.'~) leClLlI?~,lllcl wil:houl cOITlidell1ii.11 C(IU~:;l" 01 death -".",.,.~-~......-,~~ - --- -~- . ..-....-.......-".. C9 _City:::___ .'..0/2 VIII -_2~ _~====-'J~UjI~~JifITI;B;I';fNii2i\N"[i.J;,~~~~SS\1VflEHEREC9IlD'SHPbLg:BE.SENiG~-----=- , I\1E\I1"1 e ...--...---...----..--..--___.._.__._____~_H______._..._._..__..._......_.~_-_..~_. -------.- Acj(\('(~JSS . ----------.------- ,- --~~ ~~ -----..y- ~ - ~-- ---.--.~-.,-~.,--.-..-...-...---.---------.~---.---.---p----.--- Stale Zip Code _--'--'- --- -~ --.... ---~ ..~ -- .-----.__ '_'~__'_'_~_' _ ~._._ _ __ ,r ...~_ __ _,_______-____ ---..------ _~M-.--.---- DRAKE LOEB HELLER KENNEDY GOGERTY GABA & RODDpLLC ATTORNEYS AT LAW James R. Loeb Rieh,lr<1 J. Drake Glen L. Heller* :\1arianna R Kennedy G,lry J. Gogcrty Stephen J. Gaba Adam L. Rodd Dominic Conliseo Timothl' P. !\1cElllufl, Jr. Ralph L. Puglielle. Jr. Gcolfrel' E. Chanin Litigation Coullsel Jeaullc !'\. Tully Jennifer E. \Vright StU,lrt L. Koss,lr Ll'nn A. Piseopo AmI' L. Zamenick *L.L.:\1. in Taxation Writer's Direct Phone: 845-458-7330 Fax: 845-458-7370 bclark@drakeloeb.com Wappinger Town Clerk's Office 20 Middlebush Road Wappingers Falls, NY 12590-4004 Re: Estate of Helen F. Palazzo Estate of Charles J. Palazzo D-O-D: 3/17/2008 - Helen D-O-D: 2/14/2006 - Charles Our File No.: 13391 - 63859 Dear Madam/Sir: 555 Hudson Valley Avenue, Sle. 100 New Windsor, New York 12553 Phone: 845-561-0550 Fax: 845-561-1235 www.drake1oeb.com June 20, 2011 We represent Susan Harris, Executrix of the Estate of Helen F. Palazzo and the Estate of Charles J. Palazzo. Enclosed is our office check in the sum of $20.00 representing the fee to obtain one (1) certified Death Certificate for each of Helen F. Palazzo and Charles 1. Palazzo. Also enclosed is a self addressed stamped envelope for your convenience. If you have any questions, please contact the undersigned. /dm/191236 Enclosure Very truly yours, , ~f-rl~~ DEBRA L. MARINELLI Estates Paralegal _._~ --.c_ '. '\ \ 1 ~ j , ./ \ JUN '2 1 20'\' -rr~\t I '-' '. -- -_."~.,.-'.~' DRAKE LOEB HELLER KENNEDY GOGERTY GABA & RODDpLLC ATTORNEYS AT LAW .lames R. Loeb Richard J. Drake Clen L. Heller* :\1a rianlla R. Kenllerly Gary.J. Cogerty Stephell J. Gaba Adam L. Rodd Dominic Cordisco Timothy P. McEldutl, .11'. Ralph L. Puglielle, .11'. Geoffrey F.. Chanin Litigati()ll CC)llllSl'l JeaUllC :\. Tully Jennifer E. \Vright St uart L. Kossar Lynn A. Piscopo i\my L. Z,ullcnick *1"1,,,\1. ill Taxation Writer's Direct Phone: 845-458-7330 Fax: 845-458-7370 bclark@drakeloeb.com Wappinger Town Clerk's Office 20 Middlebush Road Wappingers Falls, NY 12590-4004 Re: Estate of Helen F. Palazzo D-O-D: 3/17/2008 Our File No.: 13391 - 63859 Dear Madam/Sir: 555 Hudson Valley Avenue, Ste. 100 New Vlindsor, New York 1255:3 Phone: 845-561-0550 Fax: 845-561-12:35 www.drakeloeb.com June 8, 2011 We represent Susan Harris, Executrix of the Estate of Helen F. Palazzo. Enclosed is our office check in the sum of $10.00 representing the fee to obtain one (1) certified Death Certificate for Helen F. Palazzo. Also enclosed is a self addressed stamped envelope for your convenience. If you have any questions, please contact the undersigned. /dm/189846 Enclosure \ I I t \~~- JUN 0 9 201\ r uct-LIt -li'--J~ Very truly yours, . ~Lr//0~ DEBRA L. MARINELLI Estates Paralegal r[-::::~ UJ; rrnR \ (~~~J NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record .....'...:-........................................................... .........-.................................................................-........................,..'.... . ......................................'...... ...................................... ............,.......,............. ...................................... ,-. -.... . . ...-.. -.-........ MjA.ND)ENeL ... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased (0 II L111 Mr FIrst M\ddle Name of Father of Deceased (}JltL TG~ C First Middle Maiden Name of Mother of Deceased fvt AR V First I Middle Place of Death V A5~A,e /..I.r..,$/)r7IfL Name of Has ital or S\reEh Address Purpose for Which Record is Required kLu"t- Last /(LUc Last Date of Death or Period to be Covered by Search b ! 22 ..:2--0 II Social Security Number of Deceased N~fItY Ob "2. -If 2 - (& '0 /qS-( Year Age at Death b() p(ArCHG~ Coun (;J/JffINq 'Et.S FlUL.s Villa e, Town or Ci What was your relationship to the deceased? S f 0 L{ ~ 7i- In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Jr' .~ 1,' Date g I' I ~ II Address of Applicant 52. ktltR-R./It(!:(& HILL LI}/JG I f(){f($flJ::-i:~SIe-, N r I 2603 L Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) J v NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record . . . .... ...........PLlitASECOMPLETEFORM ANOENCL,;OSEFEE.<<>>. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~lr\ ' B \SE> Middle ..':':\':.PlJ::ASEPRINTORTYPE ........ .... ......... . .. .:<..... .. .Date of Death or Period to be Covered by Search k\~ Last ~, 23" 2e,\ \ Name of Fat er of Deceased v.e'~nCJr\ Fllst C. Middle <S:c T\- Last Social Security Num er of Deceased 6C::9 - L..{ 2 - '~9-D Maiden Name of Mother of Deceased ~I\dn:c\' g 5n1lTh First Middle Last Place of Death \ 0 Connor Rc:\ Name of Has ital or Street Address Purpose for Which Record is Required . . enJ of ~~. A~\~ Date of Birth of Deceased ~,^l~ \<6/ (9'10 Month vDa Year Age at Death -=t-\ c::u+c~ Count What was your relationship to the deceased? ~Vle..J't>.....~ b, '("'eC..'tt:r2... In what capacity are you acting? cI'\ k>emlf 00_~WlI~ If attorney, name and ionship of your client to deceased Signature of Applicant Address of Applicant p::ae,:seNT:):(?)/: t!t::(::){: {(:){.}::::::'::.:} Name _ Addr ess City _______ State Zip Code nnl-L ?QI1l\ IRI')()()()\ ~ Office of the New York State Comptroller Thomas P. DiNapoli New York State and Local Retirement System Employees' Retirement System Police and Fire Retirement System t 10 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.state.ny.us/retire 11111111I1111111111111111 Town Clerk Town Of Wappinger 20 Middlebush Rd Wappingers Falls NY 12590 July 18, 2011 In reply refer to Reg No: 30615017 Ret No: B05818161 SSN: 100227335 Unit C: Pensioner Services To whom it may concern: We request that you forward a certified copy of the death certificate of Joan Lichtenberger, social security number #100227335, who was born June 2, 1929, and who died February 9, 2011, presumably at Wappinger Falls, Dutchess Co. The certificate is for the official use only by the Retirement System to close the pensioner's retirement case and determine benefits payable. The certified death certificate should include the manner of death, unless prohibited by law. This is needed because under New York State Case Law, an individual who intentionally causes the death of another person forfeits any eligibility to benefit by any proceeds that may be payable as a result of the death. The Retirement System must determine that individuals named as beneficiaries are in no way implicated in the pensioner's death. If payment and the completion of a request form is required, you will find them enclosed. Sincerely, ~~ Robin DiScipio Employees' Retirement System Examiner IV Pensioner Services Section RDfRT333 ,\ ,7 -= ----., \// iL,,,,, 1[5) I JUL 2 5 Z~I;'~') I TOVl/i\! (" "" ~..""" ,>~ 6'~ TO' < . il! l:J;:: R Vi l f\ i ,",< 1 '_" ' '- I - - ~ ,.J \...1. t"R" f/ --------- " .... , ~ \ --- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ...... . .. '." - . ...-.....,..'......,......'.............'.'.........-...'...............'........,.. . ................, ............. .. . -... ..............-. ............ .... ..". .....................,........,.......,.,... . ...~~:?PteASE;~Q.. . .. MtANDiiENCU;.OSS,iIEEftt:tLtf ....._..-.-..;'.'.....'...-......;... ~:~:~:~:~:;::::;::~:::::~:::~:::;::;: .. .., .'-........,., ........ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased First~e>1f Middle ~. Name of Father of Deceased :::: :.:... . .. : l> : \, ",;:, :.;. Date of Death or Period to be Covered by Search Last~Ric b/S-/r Social Security Number of Deceased First<1o'1iUc ') Middle Last W~ Maiden Name of Mother of Deceased Date of Birth of Deceased First .~/{ " Middle Place of Death / tC- /tp;::' I ,..; A.....-6 Month Da Year Age at Death I ~3z- Name of Hos ital or Street Address Purpose for Which Record is Required (1,vA <I- tJY Coun }uJI/ "" f5 What was your relationship to the deceased? '5", A..J In what capacity are you acting? ;tJ~ r ~ ~ 1::,"/ If attorney, name and relationship of your client to deceased IV / /'t- Signature of Applicant ~ 7, ~ ~ Address of Applicant ~ 5/1tAPt:;ffl Ifl/..L.., 1111l.1~"uIp.J,y' Il.;rl Date 7)' 1/ ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coer of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased mfrR I First Middle Name of Father of Deceased Last '." . " .. " :::::.;:. ..:;:;::. ,of L ;' ~/P.OOd to be Covered by Search Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last Date of Birth of Deceased Age at Death First Place of Death Middle Last J 6- L( 0 s-L rJf .'1 c f-h { ( Month q lel /6' Year Name of Has ita! or Street Address Purpose for Which Record is Required fVYSP T1\Vc!r I/IIvrp P Villa e, Town or Ci Coun What was your relationship to the deceased? In what capacity are you acting? 0 Ft-=rc...t7-\C. - /" '7 J (J If attorney, name and relationship of your :Iient to deceas~ r\ v 7j~ /h~ Signature of Applicant \Iv-. Address of Applicant IV Y S P hi /1 !!':Jyv ([. I L Date ~ '(1/1/ - Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record '.' .' ... .......:PLeAsEcOMPLETEFORM ANOENCL,;OSEFEE.....:........}:::.'..:....... . .:" :'.' .'. ....:. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name at Deceased YtJ tJ;U '..J / I :'::',"PlJSASEPRINTOR tYPE < ...... . ... ..... . .... ... .....: . ':." 7 / Date of Death or Period to be Covered by Search f~/7LF/o7- 7 -j - / / Fllst Middle Last Name 01 Father of Deceased _p ffLC;~..L/ Social Security Number of Deceased 'vtJ/f.../V j--!,;::-~ // 69 7 _ "7?_ P 7 L/ Q First Middle Last c. / / ~ Maiden ~ame of ,Mother of Deceased p r"" / /' / L/ L- L / /'1' /V L /9-/1 ,--. C-LL- First Middle Last Date of Birth of Deceased i-z / ~ Month Da 72- Age at Death Year 7P Place 01 Death J72 c/f~,n-t.;F 2J~~ Name of Has ital or Street Address Purpose for Which Record is Required tultfl//l/6F/~ r-~ff f t/7/lffI/E Count DFI9 /77 ,r/J/~~L What was your relationship to the deceased? /Cf/~ In what capacity are you acting? If attorney. name and relationship of your client t Signature of Applicant ~ - "1" Address of Applicant 5T Ii: ~ I \. \"7 ;P.....,.. _ f ~o p' & /_ jJ/~~C70/C II "::':;:'COMPLETe FOR DEATHS':'OCCURR NGASOF' Ii. ~ Number of copies requested with confidential cause of fr5J -- Number of copies requested without confidential cause of deilitfi dec~e~ ':::, {~ Date 7-!?--// sT ~~/~~ ~'-CS fty /ZS- 6 .-.. p. -----l I .....:.:::::Rt:eA$l:tJtRI NTNAMe::=:ANtfAoOFlE$$i .... . N1Gn;::::::::::::::{n::::.::.::::::?i.:..::.::t:::::r::::)::}:t . ,-",.., .. ... .. -.. Name Addl ess City State Zip Code DOH.294A {6/2000\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for ColD' of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: S 10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PAINT OR TYPE 1S~~;:y First C;~~~/- Middle Last Date of Death or Period to be Covered by Search t: Cj /2-' 1/ Social Security Number of Deceased Name of Father of Deceased jus c: YJ ~ S e- k l.{ t:. cre"-\. First Middle Last Malden Name of Mother of Deceased J tvLt ~ tlo J I '-'~' First Middle Last Place of Death 51 () ~ Iv--c.' y I'ZerA-O Name of Hospital or Street Adaress Purpose for Which Record is Required b'/ ').~... 2 Y -7 tJ'eo ( Date of Birth of Deceased Age at Death /1 S...... J7/7 ere.- Month Day Year W/fI'~J1I G-e ^' b r..trCil.(~ S County What was your relationship to the deceased? AI'" A/B . ~' In what capacity are you acting? ~~/V~ ]) ~/ee-C~~ If attorney. name and relationship of 'your cliert to /""J tr . Signature of Applicant Address of Applicant COMPLETE FOR DEATHS OCCURRlNG AS OF JANUARY 1 1983 -k- Number of copies requested with confidential cause of death {R1~cc~n~~lD) _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE A Name Address City State Zip Code IN DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local ,Registrar for Co of Death Record ::;~:~:~:~~~~::~:~:~:j:~:::j~~::::::::::::::::::::::::::~~::::::::::::::::::::::::::::::::::::::::::::::::::::;:;:;:::;:::::::;::: :BCEA$$.:(n'MPCeOC$::eoau:tttitQRNOJ4OSI$;:ltEe::m). FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~{~ceased . . First ~ Mtddle Name of Father of Deceased G.!}. ~t\ .i~t:Pf1JNT}Qtt~e:{;: :::::::::::::::::::::::::::i:i::::::::.::::::::::/::::: Date of Death or Period to be Covered by Search o~1 oq \ \ \ Social Security Number of Deceased .................. .................. . ................ ...... .......... .................. First Middle Last Maiden Name of Mother of Deceased First Middle Last Place of Death {\ \ . S\ 0 'ff\a.\o 1\ ILv\ l'vO r\~\ f<~ Name of Hos ital or Street Address Purpose for Which Record is Required Date of Birth of Deceased \ \ DS Month Da i7 Year Age at Death 9s b~~Qss' Coun What was your relationship to the deceased? I n what capacity are you acting? L... '-' ~Y\ ~ ~ f L.. '-- ... "'\-' If attorney, name and relations . of your client to de ased Signature of APPIiC~ Address of Applicant I ~ M \~} Date~ '1.) I'( o :::::::I::::t:t:It:m:::::t:::::::::t::t:::::;;:mtt:I{::m::::'::;.:::.:::.:::.:::...:...::..:.::r....:;:.:.:.:.:.:.l:.:::::.:::.:::.:::.:::::.:.:.:::.:::.::;.:.:::;:-=;:.:.:.:"'::''\(:;':::':;:::'':::';':':::':':':':':':':'::r:'::':"'::::f:::::':':':::::::';::':':';::J:t:::.:.:::.:::.::.~.:.:::.:.:::.:::.:::.:::};;::.::::::::::::::.:::':':':':':'::::::::::m::::::t:m:::m::::::mm::I:::::::::::::m:m:m:m:I:I:\::::mmtI}I::II::::::: .a. Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State DOH-294A (6/2000) .- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record .. ,.-. . ..... .-............................................................ ":;.:::::::.;.:::::.;.::;::::.:::::::.:.:::::.:.;:;:;<::.;::.:.:.:.:.:. ..........,......'.>>.................................. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ya-,fj ~ First Middle Name of Father of Deceased -r b f-/ tJ J--/' First Middle Maiden Name of Mother of Deceased :1 t;; {1/ pJ I t: First Middle Place of Death R J{ 6f Ltlt1f1.T1JWtJ 0 Ai> Name of Hos ital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search & /J l.. L- It 6Nt:--i!... Last 6Utf:R.LA ~ih Last fl) D If J .J- Social Security Number of Deceased Date of Birth of Deceased ~ S~E(, L Last Age at Death a<t IV Year 8-5-- b l! r t..;I ~S ~ Coon .--c- ~N-SUr<.AN~ What was your relationship to the deceased? m I 0 r /-1 e Ie. In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~ ~ Address of Applicant '1 (/4!fl. ~ l' ~,g tc"]V' ;r:$ Date ~ - 1/ ~f. F/~l/kL'- IV; ~5"tJO . . . . ..' '. . ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of de Name Address City State DOH-294A (6/2000) \':.. J v NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record , ':pteAsECOMPLETEFORM ANOENOI.;.Ose:FEE> FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name ot Deceased NcA' ~ FII5t Middle Name 01 Father 01 Deceased .,'::-'pl..eASEPHI NTOR Date of Death or Period to be Covered by Search ~Y\IS Last ~-'2-\1 SOCial Security Number of Deceased ~ " First v- Middle q~--'e,~r Last O~ '7 -:s-W -CY'iSS Maiden Name 01 Mother of Deceased Date of Birth of Deceased Gry)'C\\c., 9vti~ 7-Z \ - ~ \ First id e Last Month Da Year Place of Death_ '~ 33 S~V\ ~ +----$~ Name ot Hos ital or 'fWeet Address Purpose for Wh,ch Record is Required -t:Vtd cR u * Age at Death 7-0 ~~~ Coun What was your relationship to the deceased? ~A.~\ U' rEo Q1zrL In what capacIty are you acting? ~ ~ \ .p c:::::s-~ ~\ ~ If attorney. name and relationship of your client to deceased'/ SignatUleofAPPhcanf~ -~ ~ Dafe ~-- '--{ - '( 'I, Address of Apphcant ~- -\?l~ ~I~ ~\\<;"M $~ f" I ~ 'COMPLETE FOR DEATHSQCdURRINGASOF' I '1 'I Number of copies requested with confidential cause of death (R{~~~~~~fO) __ Number of copies requested without confidential cause of death ";'.:'":::;:,::::::::;;: ...pL,;eASE'p'RINTWAMe::ANO\4.PDAf$$:WHEAE<.'ReCORP>" Name Address City _________ State Zip Code ~AA IR"""'" NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record . .. .~""'~..... .... / .:pLeAsE coM P[ETEFCRMANOENCLOSEFEE>< FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. . . . . . . ... . . . ........... ,... . Pl.EASE PRINT OR TYPE > ..... ....... ..... .:.... ... .. Date of Death or Period to be Covered by Search N~ Dec~ased 1/-l.5AJ /In Fllst Middle Name oJ f ather of Deceased ttAf/lV/J / LFJ/;/C First Middle Maiden Name of Mother of Deceased MiJ /17/1 Last 7-1/- /, Social Security Number of Deceased Last /~~. 5tJ. ?5tfc:z. First Last Age at Death Middle Year f3 ])tt/cks.s PI;I fi;/~ lJ i / OR Name of Hos ital or Street Address Purpose for Which Record is Required .f ~I-h What was your relationship to the deceased? In what capacity are you acting? If attorney. name and relat:);" on " _of your ~~' to dece",,~ /.~. ~~-/~ S. f ./--.) C Ignature 0 Applicant -- Address of Applicant 65" C;; Jk.J1 , "t/~ /tkff -.0/507 S /tOt.L~ t. JJ'Rt J Date 7- );2-1/ /H//..s AI.V. .6?..5~'o / / ,.... ...... .............,................ .-.............. .... ..... .... .}1':::H98s'\\/J::::::it::;),::;I,::;iF:,}f:,;,.:;:':: t. I '\ __ Number of copies requested without confidential cause of death <>... ....... . ....... ":.,:.;PLeAse'itRI NTNAMEtANb\AOORE$.$TWHERERECo.flPSI101;tcoae.SeNT:)/U\},)tW<,:}:::\<:::;::#:::::U\t Name Address City _ State Zip Code ~/ 1l/l1...I.I)QaL\ /f;/?()()()\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record .......:... .... ..PLEASECOMPletEFCRMANOENCI.OSEFEE..>..... ..' ............ '.. . ":'. ....:.. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased t:clWI1/LcI Fllst Middle Name 01 Father of Deceas~ iG~ tV;}, 'ed 0:> . First Middle Last Maiden Name of Mother of Deceased hA // CmfrJl7 /I'/{)!Z r'/lt{ f- First Middle Last tJ' .f?' , Al-J/f1Cd .......................PlEASEPRINT OR 0/ Date of Death or Period to be Covered by Search .QJ./Jlz Last t./t,. /1 gj/1h Social Security Number of Deceased //0.3&,1/3:2 Age at Death Date of Birth of Deceased t- /f 3tf Da Year /-2 . Month 7c::L Place of Death '/ Russ pj. Name ot Hos ital or Street Address Purpose for Which Record is Required ;Jk~c?he sS Count ?el1 'j, What was your relationship to the deceased? (;;A/cK /J i In what capacity are you acting? If attorney, name and relationship of your client to deceased QSe- Signature of Applicant Address of Applicant 65' C. /J1/'?, I S:;. JUL 1 2 20 i ....... COMPLETE FOR DEA THS bCCURFllNG AS'OFJANlJ..' "i1"'198S:::{n':::(.":'::::,:::;:: , .8 Number of copies requested with confidential cause of death __ Number of copies requested without confidential cause of death ......PLEASE'ffRINT.NAMeANDAPQRE$.$WHEREJ~t;CORP$l'iotO,..paESENT:::';':?) .... ..........." .......,.. ...,........:-.........:.....'....,.,..........'.'.. ......................................,......... ........................., ........,..... ....,..'.... .... .............. .... Name Address City ___ State Zip Code <'!f DOH-294A (6/2000) 1\11=':VV YCml< ;:.~TATE: DE!='AI=1TIVII::I\j'1 01::: I-It::AUII Vlli::11 HHcUrcl" (:;\OlclIDI\ ...-- -- -- .....11."....\ttfW~~...UfI__I.J;W~I~l:alla.w.llllillllWllUlWt.audJJMI'.m'"*.~............ App~ilcation to LOGar R'egistr~r fou CoPy of Death Recot ~ ---~=-=-=:======-~I~J,\~:f.: c;(~1"!l117~1~i~)illvTA:-l\m.ENcLoSE.'FEE. . ::::'><';;': .:::<::::..;.... I:EE: $'1 0.00 pl~1 copy U11\Jo Ill:)colcl Cl:)llilic:alloll. 1:'108S8 cia not send cash 01 stElIYlpS, ~---_.~~. ~--- - "- --~..--_.....-~- -~ _._ _ _ri'~--""~ _'_'_ ~______ _.__ ~___ ~=~~~_~~-----'-'--"~C-'-----'~'C-~~'-'I" Ij3A~SH~PR'INTOjl iVPE . ................... .. .: . .: . ..' 1\1;::1111(-) or D(:1ce;~~d.--'--.- .---..-------......---- ~Dr;\t8-of Dr:JEll:h or l:Jeriocl to be CoverecJ by Search ~t<AI\JJ< 1'. SC'RI\J.v~ --- .__i!~!__.__ .._._.__.Mi(lclll~ I_w.t hJemle) of Fi'1lhm 01 [J()Ce"E1S0!cl--'---''''--'- ._____n _m._ ----.SZcial ~~8curity l\lumber of Deceased ONOFt</o SC-'I1IVllIfl ,__ 1::11:0,1 Miclcllt' La~jl ~~-~-.._-~-----_._~.----- ------~ ---. ~ --~--........---.~,-- IVI[IICI811 l\lame Dr lV1ull)(H ur OC)Cei:t::-'8cl Date or Bil.th 01 Deceased ~ 051/1111 5 oRL, ~ If, ~~:::'.!..._--_.._._-~~J~__ La~;l Morrill Day PlaC80lIJHalh I ~ 1="ULTO~--~~~---'----'---- i-J ftI'PIfJ&~~ FALLS 7-;)./-1' () 5'"5 -14 - g d.q ~ I 'f,1 Year Age at Death q J J~m!~~ or~loSIJllal ur Stlt)8t Aclclrl~::":c; . Villi:1Cj8, Town or City 1::1 L1rposl:!1 D~\lVIlII;f;r:18~o!cI-~ Il;l~;~i"---"--'-'--'-'--' .J)UTGI-JESS County -, ---.. -------_.T 0 .-~.~:!.I~€ __~:?.I_'~I.~_______ Wllul. Wi!.'; your 18li:iIIUnslllp to lilt! dl~CE!i\St'cl? ____EuNEf?.~_.)) ( f2e:,,-~-_ III what Ci'1j)8crty 2!t:' you i:lcli"g?______~-..$fl.!!:'J.i:.----- II il11oIIWY, I)i:illle nncllOlcllioll:,1111) ur yUU! c:1181"11. to cloc:edsl~cI ----~ ----- l>iu"nluI8 01 Applic<lllt -~._~~~~.,j'''2 Date~-~-'-I---- . l\clcIICSc! 01 J-\pplicrJlil ... t.!L-.e~f12l1/..1L_$I..._W.tll'..eL -~-US- PI9'-:LS, A.J. Y. / ~f{"9o -- ~----------.-.- .~-- "-..~~~~~--~ - -----~ _._~----~--~-~._--- ~ ------.----~._----------~--._----- -- -.- ------.-- -- -- ------ -----.--.--..... ...... ..CO NIPLETE .F,Oj':i nl'~.!.\"[~.lcl.C\('l('(".I') 8:1:;> I'N.C.;:A.c' OF. dAN.LJARYl:li9BS.:..' ---'-,....-_____.-.:.,,~....~____::_._::..:..:~..:."__:.__._~....::_:.:_:~_:~~~ . I ---8_ NUlnhCH 01 C:Opi0~~; 1(:lqLll~~'iI(!C1 with cunliclr:!lItinl C,:1Ll~)U Df cleatll .-....:. . ",",-, '."'...: ',. I\lurn!lI;.)! of CUpil;'S !1"!C1L1I?~;t(;c\ without confidelll.ii.11 C21U~)l'! or cleath ~ Inl -.,."..,.---..........~.~~- -- -_.-~- . --------.-- ._-~.... .-.~ ---- ~~__ ..._r_._~____ IL=__=::="J~LCifS.@:PfiTI;~N~~~i~NjjlAi!I5Eli~sswtIEI{1,.jjE'2f~~);~~~~..s:m~w;;s:.~ 1\1[111'18 .._--_.._--.-._-~_.__._-- -_._~--._--.._-~-._-.-.~....-~..._,.._.~.,--_._.......... -..-'- A elelll'; Cl~) ....---_.. ~-----~._-.._---~_....-.._~-~- ---- ._~ - - - - ,-~ ---_._~_._-----~--- City _.____~__ StalJ) __' ._---.~-~.~..--..~-----_.._~--~--~_._._---_..._--_._--~- --~- Zip Code _-'-- -------- - ----~._- ~ --~----~-- -.----"-. -- . ~-----.-.-.---~--~-- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local ,Registrar for Co of Death Record ..p............................. ...... . ............................... - . . ........................... . . . . . . . I . . . . . . . . . . . . . . . .................. ~~~j~\~~~\~~~~~~~~~~jj~:~~~~~(j\~~~~~~l;j~j~j)~~j~j~~j:jj::~~l[l:j:j~:ll[~~l:jjj~[::~~~::j::::::::~~::::::::;::;:::::::::;:;;:;: ,.,.... .c.,...,............ ..>,..... ...M'.... ""'E' ro' "e' ....fO.. "S':"M" "'Aj'.....N..'..D...c"e.'::N..'.C'. 'U""'O':"S":'E,,'::p":e"::e'.':;:;:<:;:;:::::::;:::::,:, ..ru:;:e.:A<a:E"T.'>n P'::':'" .....c.. ........ .......... .............. \r::~..::~~.: ):~~ . ....::::~.:::~..::. .::::v:....:.. .::: .,' :{ :-:..", : :):. :. ..:........:" .": . ':.:: ," "':::. .:;:..::.. ":::::::::::::::{::;:::::: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :e.:::Pfnttta::)f:ttGIRe::'::m::::@:t:m ..,..... ....... ..... ;;;,,'::'::;;,;:,:;.. .. ., .. Date of Death or Period to be Covered by Search Name of Deceased (ASNIr1\ First Mlddle Name of Father of Deceased rtfT7 rY11t Last Social Security Number of Deceased . /22- <30- 1;S-1S'7- Date of Birth of Deceased Age at Death f7- <-7- 27- <? z. Month Da Year ~Af(J)lJ5dL r;" I~ \)JTZh~S5 Villa e, Town or Ci Coun \ -- \\ , '\ ~~~:mm:m:::::::::~J:m:::::::~::~~t;:lmtrlt:~::::t::l:::;:m~ir:::':::':::':::':::':':':':::::':J';"'~::':';':':':'1:':::::'::;':::':;:)(':':::':::'::":':::;:':::':';'....:::.::~::.:::::::.:;.:::.:::.;.:.:::.:.:.:.:.:...:':::':':':':':':"'::::/:':::':':':1:';::':':'::'::::::.:.~;:.:.'t:':':::~':':(''?:::':::':::;:r::':{:~i;:':::...:.:.:.~~:::::tt:U\i;.t::::tmmm:mt:m::gt:t't:rJ:f:t:t:m:m:m~::m:::::m First Middle Last Maiden Name of Mother of Deceased First Place of Death Middle Last / / 1/ sfi/L )~/l \)1- Name of Hos ital or Street Address Purpose for Which Record is Required ~LI~S What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased h Signature of Applicant Address of Applicant _ Number of copies requested with confidential cause of death _ Number of copies requested without ccmfidential cause of death ~ \ \ , ",~;f,I \ '\ 1-121":;\ Name Address City State DOH-294A (6/2000) Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record PLEASECOMPL.aE'fORM.ANDENCLOSEFEE .. .. ." FEE: $10,00 per copy or No Record Certification. Please do not send cash or stamps. PLJ:ASEPRINTOR T'fPE Name of Deceased Date of Death or Period to be Covered by Search Ana Quinones Reyes September 1 , 2011 First Middle Last Name of Father of Deceased Social Security Number of Deceased Antonio Quinones First Middle Last 580 82 7639 Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Oeath Monica Bonilla February 21, 1940 First Middle Last Month Day Year 71 Place of Death 62 Imperial Blvd, #3313 Wappinger Dutchess Name of Hospital or Street Address Village. Town or City County Purpose for Which Record is Required What was your relationship to the deceased'? In what capacity are you acting? Funeral Home If attorney, name and relationship of your client to deceased S~natureo1APP~~~k~~ Date {( 2-!lr Address of Applicant 895 oute 82 Hopewell Junction NY C "':"'1E;!': " ;'0': ~ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death pt; Name Address City State DOH.294A (6/2000) SEP 0 2 2011 TOWN OF WAPPINGER TOWN CLERK . Application to Loca' Registrar for Co of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of. Deceased \jcA\en (6 E First Middle Name of Father of Deceased ~<0(\ 'f( C;<:::> \ \ ~V.J First Middle Last Maldan Name of Mother of Deceased Date of Birtl1 of Deceased Age at Death ~en"e G",Ic..\--A.ci;;2 bl!.;, ICj;:11-.r:: First Middle laSt Month Da Year ':..J Place of Dea.!b--J . "2::J b' Y (C)-::'oeC\ s'\-\Ce-r, wD-oP..,c.er"" ~0 \ \:;. ~ Name of Hos iIaI Of Sir..' Address Villa Ul, ToWn Of '0, Coon PurposefcrWhIch Record IS Re~ulreQ ~h C0-"" , exce rt''\UI,wiu af:;,\<:<.,,, In:)C<-U..-<:" 'Qen"" \> 0'< ~sbone\ ~n a yt,e........o<-hGA W<b (XA$ ~y: G..-- ' ~o\O . What was your relationship to the deceased? Q.\\c:r-I\€.A-J.' , In what capacity are you acting? ()jb'\f\E..L1 If attorn~v I name and... _ rnshi Y"'f ti . I!O d';"'ased .6>J.\", :s ~ \<::0 \d, \::t o..tb<'nQ.'1 .I.;-o( e~ 0 ' ~.)bqrC' :.m,,... ~ \..(.~.-n~ln, :..S,:, :.::RI. : ,t.: '8:::: :l:':: :.:. i / Date of Death or Period to be Covered by Search ",e.("<xchCAY\ 4 \ ~\ ~()aiJ Last I Social Security Number of Deceased O~I- ;;)~- O\SD Signature of Applicant Address of Applicant ':i::}\w::::\:tt:r:::::::)':::::Mii:i:::\':IWkMMf .;.:.':....:......:.....r .';'...:.....'J :;..::.::.:\f.;-:....:..:...\ .;;.:...\\.::.:;-.. ::...;,':....,'. '.: ..... .,:. Y"::" _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death :{{{::::,::}}}){,:::::}}::::::}},::::{}]:p:: .: : Ii" ..BINIP .:: \*.: ';j:: :., . "~:i~\~~~~~~~~ c~\.~~P' e State N-I ..................:........... ......................................... ~ Zip Code IdUJ~'" J h~ DOH-294A (6/2000) KEITH S. RINALDI, P.C. ~ttorne!,s anb (!tounsellors ~t JLaw THE RINALDI BUILDING TEN ARLINGTON AVENUE POUGHKEEPSIE, NEW YORK 12603-1604 FED lD#: 14-1660058 FAX: (845) 471-3003 TEL: (845) 471-3000 August 31, 2011 Town of Wappinger falls 20 Middlebush Road Wappinger Falls, NY 12590 Atten: Vital Records RE: Valerie E. Kernochan Gentlemen Please be advised that we are the attorneys for the Estate of John O. Kernochan, who past away on January 20, 2009. Please be advised that we need one original Death Certificate of Valarie E. Kernochan, in order to process insurance benefits for the estate. Our check, payable to your order, in the amount of $10.00 in payment of your fee is enclosed. Thank you for your cooperation and courtesy and time and attention to this request. Very truly yours KE'TKLDI' P.c. BV:~ . t.~~ 9&-< KEITH S. RINALDI KSR/JCV-W lame Ene. , tf NEW YORK STATE OEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record .... .......,................ ....,.,...;-..;.;.:-:...:...;.;.,.:.:-:.;...;....;. Name of Deceased .' Pvj I<fS f/l.G\.v;e.. Step h o..l'ct First Middle Last Name of Father of Deceased yv--e.s First Middle Maiden Name of Mother of Deceased .' I .' . . . :~:; ;.::. .: ;:(':.: Date of Death or Period to be Covered by Search Octobe'{' l~} ,It)'b ...-......,-..................,.........,.... . . ' . . . ' - . . . . - . . . . . . . . . . ...n.................. ......... . . ..... .. .' .... .. . . ......................................... .................................. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Social Security Number of Deceased fY\ e. i I t (j..;'('" e, ~ Last Date of Birth of Deceased Noy'e.~V\be,r ,5, I q 10 Month Oa Year Age at Death 7~? First Middle Last Place of Death 8 ( M ~Y' k eJ st 1"€..e.t Name of Hos ita! or Street Address Purpose for Which Record is Required Self W~frjnCje('.s: f;..l& Villa e. Town or C' V ~tc/~ e SS Coun What was your relationship to the deceased? fY) 0 t ~ e.. r In what capacity are you acting? E X e uSo Y' If attorney, name and relationship of your client to deceased S;gnabJre of AppUcanl ::f.2~ !)u.J ~. Date I1-1.i. ~. .2' 4 I ;l, 0 )I Address of Applicant 6l Y' et 'STy-ee t , LJ,,-I'-~as fCd.ls I Ny I ~ S q 0 _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death ..............,....,.......,.-....:-..... ".;'.-:';':':':;'.<:::>:':';<':':':' ,..:.....:.:.:-:.;.: Name Address City State Zip Code DOH-294A (6/2000) ~~ COn'l'11ISti\O''\8l' Of MolO! \Jef"\il.les \0".437 457 2,26 .... 11~tJ ~ ~ (~) I~J<~ DRIVER LICENSE DO~O-1~ . _~~~BE1"HIS w~"P'NG~S~ NY 12590 ~l'!'lt f EYEI~ HT: 5-03 CLASS 0 i 1$sIJE\): 1.1-12-04 EXPIRES 11-19-12 ~.CW"'>> 3a43944O.j -.'" ~ stefhC1uv t /0- (~-j9rfG, J1dY a\ Office of the New York State Comptroller Thomas P. DiNapoli New York 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.state.ny.us/retire \ "'''''' "" \\" "" \,,\ Town Of Wappinger Town Clerk 20 Middlebush Rd Wappingers Falls NY 12590 August 11, 2011 In reply refer to Reg No: 20109104 Ret No: OS5486630 SSN: 113264631 Unit C: Pensioner Services ~\Sr To whom it may concern: We request that you forward a certified copy of the death certificate of Elaine S Gray, social security number #113264631, who was born January 19, 1934, and who died December 25, 2010, presumably at At Home. The certificate is for the official use only by the Retirement System to close the pensioner's retirement case and determine benefits payable. The certified death certificate should include the manner of death, unless prohibited by law. This is needed because under New York State Case Law, an individual who intentionally causes the death of another person forfeits any eligibility to benefit by any proceeds that may be payable as a result of the death. The Retirement System must determine that individuals named as beneficiaries are in no way implicated in the pensioner's death. If payment and the completion of a request form is required, you will find them enclosed. Very truly yours, ~,,-d-",,-, ~-~qj- Linda Doherty Employees' Retirement System Examiner IV Pensioner Services Section LD/RT395 lPd~~~UW~[Q) AUG 1,8 2011 TOWN OF ,. TOW WAPPINGER N CLERK - NEWYOF,K Sl"Al"E DEPARl"MENl" OF HEALl"H VItal Records Section Application to Local Registrar for Co of Death Record . :'PLEASe.'COMPLETEFORM' ANO'ENClOSE-FEE '......'. ......".. ",::-,-:.:;", :.<::/:>.... :.:." .' FEE' $10.00 per copy or No Record Cert,I,cation. please do nol send cash or stamps. s...l'V'\vO- \ Fn st Middle Maiden Name 01 Mother 01 Deceased ~~ ~nefd~ Fil st Middle Last Sl.nc:.. ~ 'o~ \12- Last Social SecLlrlty O(g\ . ;......;.;:;..;;::..;:... . ",:,,:.;:::.;-. " .....,.. :<:'\::"PL,EASE'PRINTORT'YP Date of Death Name 01 Deceased ^ \ 0-"-'" ~ . fll~;t Middle Name 01 F all lei 01 Deceased ~, c~ ~\.I\O, ~ . Last Date of Birth of Deceased \ - 2-G\ - \ (Q Da Age at Death 9.'6 Month Year Place 0\ Death c; \4.t'\t ~ ~~ Name 01 Has ilal or Street Address Purpose tor Which Record is Required \r-t~\ ~ \::o.l ~ ViII , Town or Cit .Dt~ Count ~ ~ Lk A-~(f~ W~lat was YOllr relallonship to the deceased? h.\.~ In what capacity are you acting? ~(\ k~1 f o.\> It attorney. name and relationship of your client to deceased Signalure 01 APPlicantt . ~ Date 'I:;. AddressotAPPI'cant~~O ~ ~ ~\~P-, tn\~. \\1 ~ r-ec:...~ fuV'll.l~ ~-li-\\ ~-f \~() . ...................:COMPL-ETE FOR DEA 'Hs.'Q'CdURR'iNG..AS..OF.:/}........ l1:~\ Number of copies requested with confidential cause of death - \- '- _--- Number of copies requested without confidential cause ot death \ ....,......... .................. \\ ~o....\ S2('J\~ '( e:-k.~no;. .' ............. .. ...... ..........,.... "'iiP.L;J;'ASS.':'liRI NfNAME'ANt):'ADORS.$$WHERs.ReC'ORDSHOlJtoa~::$ENi\'/tt.{\:{:\e~.:{ri('Y{}N<{f: Name __-- Address CIty _________ State Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section APplication to Local Registrar For Cop of Death Record FEE: $10.00 per copy of No Record Certification. Piease do nol send cash or slamps PLEASE COMPLETE FORM AND ENCLOSE FEE PLEASE PRINT OR TYPE Name of Deceased Date of Death or Period to be covered by Search Joseph S. O'Connor August 14,2011 First Middle Last Name of Father of Deceased Social Security Number of Deceased Joseph O'Connor 103-54-4648 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Alice Burns 9 19 1959 51 First Middle Last Month Day Year Place of Death 31 Alpine Drive, Apt. 4, Wappingers Falls Wappinger Dutchess Name of Hospital or Street Address VillaQe, Town or City County Purpose for Which Record is Required The family requests this reeonl for purposes pertaining to insuranee and property settlement oflhe deceased What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant CS2-- _. Date Au!!;ust 16,2011 Address of Applicant 1028 Main Street, Fishkill, NY 12524 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 .-l- Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Address City State , ffi21llpde TOWN CLERK DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar For Copy of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy of No Record Certification. Please do not send cash or stamps. Sherman Last Year Name of Deceased Carl E. First Middle Name of Father of Deceased Howard First Middle Maiden Name of Mother of Deceased Anna First Middle Place of Death 20 Ronsue Dr, Wappinger Name of Hos ital or Street Address Purpose for Which Record is Required The family requests this record for purposes pertaining to insurance and property settlement of the deceased Sherman Last Last Wappinger Villa e, Town or Cit Dutchess Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? If attorney, name and relationshi Date Se tember 22, 2011 Signature of Applicant Address of Applicant COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 JL_ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record PLEASE COMPLETE FORM AND ENCLOSE FEE FEE $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~ Last ~~ PLEASE PRINT OR TYPE Date of De;;7;Od fO/ ~ Cove'ed by Sea,eh SocIal Security Number of Deceased {Yt/ 7 -' Zl, ~t/tJ P? Name ?:,,?eceasecy ,.:y d 6 e; PC First Middle Name ~ther of Decec:;! ~st~lJ~ Mid~e Malde~e of Moth~f Deceased /'IA~~U{ First Middle Place of Death JJ Go it( ~ ~ Last Datff Birth 7;:ased / 9)1/ Month Day Year Age at Death Name ot Hospital or Street Address Pu'po,e 'm Whkh Rew,d i, Requi,ed {;; ~ (' ~ v ~J~ County What was your relationship to the deceased? In what capacity are you acting? If attorney. name and relationship of your client to deceased Signa'm" of APp/;canf~-;; -t: Da'" Address of Applicant)'. Z . cK.-. cY /C'-Y /d-t:cJ2 ?/; ;k f ( COMPL.ETE FOR DEATHS OCCURRING AS OF JANUARY 1 1988- B Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Address City State Zip Code ~4A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Donald Victor First Middle Name of Father of Deceased Victor O. First Middle Maiden Name of Mother of Deceased Esther A. First Middle Place of Death Residence 9 Brian Place Name of Hospital or Street Address Purpose for Which Record is Required Legal Date of Death or Period to be Covered by Search Schneck Last September 22, 2011 Social Security Number of Deceased Schneck Last Schroer Last 132-26-0840 Date of Birth of Deceased 10 11 Month Day Age at Death 1932 Year 78 ~~CC~~~mhes Coun 23 011 APPINGER TOWN CLERK What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your cl" nt to deceased dMPlJ.Usrflliii" E ~u!~r~ c~es requested with confidential cause of death ..JL. Number of copies requested without confidential cause of death Date September 23, 2011 Signature of Applicant Address of Applicant PLEASE PRINT NAME AND ADDRESSwHEReaECORO;ItIM.D. .... Name Address City State Zip Code ~94A (612000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record -:-:.:.:.:.:::.:-:,.; FEE: $10.00 per copy or No Record Certification. Please do otse~ce!w~~ 0 7/;t;;/4ed J1 eF&4t J First Middle -L1s: (jk~;;;~ceased vAlM:JO,A)~ First Middle Last 'dr;;;;;~ (o;;;r of Deceased /IJ(),J r.4J Fi~t. Middle Last Place 9f Reat~M. ' .e/'.JIet/fJJ ;vf.lW(/j~ t) u.J. "c;, fir. M ~(t6f~Di; or treet Addr't'fiF -,0 'f: Purpose for Which Record is Required cJ~d 1~f15 oa.z of Birth of ;;ased Month Da UcJN Signature of Applicant Address of Applicant -1- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death State Zip Code () DOH-294A (6/2000) ... Application to Local Reg istrar for Col!)' of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased fJ'-te tI. It 2dle Name of Father of Deceased IMU" Ie iod<lk> illh/1} Maiden Name of Mother of Deceased I j · E /)1/' V r, WF/N SftE/t1IE: First I Middle Last PliiOf5k'J -ttJP O/<.I JlE Name of Has ilat or Street Address Purpose for Which Record is Required j-/tl IV It tf Last Date of Death or Period to be Covered by Search m II V I; 02d1/9 Social Security Number of Deceased o 9ti-' 3'6 -# J./ J/ / Date of Birth of Deceased JuLy 10 /9-"15" Month Da Year Age at Death ~3 IJtife/1e-SS Coun tlJA-I~fJ/N~Ej PI/a-S; III Villa e, Town or Ci :r/J .s fA.. ~AN c E What was your relationship to the deceased? S I g -+ E k In what capacity are you acting? r l;f/ III fj- Aj l' / 13 EN F r J(', 1 fJ )( f- If attorney, name and relationship of your client to deceased SignabJr. ol Applicant ~ )fJ. a 4< t;td Dale Address of Applicant /.pH ~ ~L ,~~ f~ 15l?AC ~ ;V / N f 9!//f/~// /,4 ~1Jf;y I I I ! I I , , ! 1 I I i I I I j ! ! -'- Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death ::::::::::::::::t::)))it.tP ::' .:.. E~: ..: : Name III E f,!>> 0 pO j ; -t- ,4fl Address 71) B(J 'L .II?~?J 0 City w'-If~ tAl Ie k State ~:l' DOH-294A (6/2000) "'^ . 4/i 'fSI J 9 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Co of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Date of Death or Period to be Covered by Search 1)-\S-\\ Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last (::) \0 \ - \L\ - b \, Date of Birth of Deceased Age at Death First Middle Last Place of Death r~ 0 ~f-tA~ ~CL-\\ S Name of Has ita! or Street Address Purpose for Which Record is Required \qllo (] c Year -I u ( L\\V)\-) Coon What was your relationship to the deceased? T ( \ -tJ, C\ \ r (1\ C; f ((j i 0t) In what capacity are you acting? If attorney, name and relationship of your client to deceased #~ L Signature of Applicant Address of Applicant Date _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) ./ DURABLE GENERAl-/ POWER OF ATTORNEY. New York Statutory Short Form (with Modifications) THE POWERS 'YOU GRANT BELOW CONTINUE TO BE EFF.ECTIVE SHOULD YOU BECOME DISABLED OR INCOMPETENT Caution: This is an important document. It gives the person whom you designate (your" Agent") broad powers to handle your property during'your lifetime, which maY.'i!~ude .powers to ~Ol1ttage, sell, or ?the~wise dispose u[,any real or person~1 property WithO.ut. adva.nce no. ticet.o>. '.ou...or. ..,~ r. o.va....I.i.... .yoq.~h.e.~. e.. pow. .~rs..~J.ll c.ontim.~.~t(J.'.c~~st ~~';'ell;lftf.r you become dIsabled or incompetent. Thesep~~1,i~:,~mf.'~ ,. or'." fm~~' ,;~,'!\kw YP!'i., G~n~r~l O~h&lltlOllS Law, Article 5, Title 15,Set\ions'5- J fi{l2A t'!1f:m"gh5-15t'fJ, whi~tpre y permIt the use of any other or dIfferent form of ~:C'Wl.'r {It ~ttur.,:ey. ... . .i ' .: THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS, YOU MAY EXECUTE A HEALTH CARE PROXY TO DO THIS. IF THERE IS ANYTHING ABOUT THIS FOlU..1 THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU. This is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 of the New York General Obl!gat~ons Law: I, Alan W. Shevlo, Sr., residing at The Family Lodge, 108 Main Street, Saugerties, NY 12477, do hereby appoint Mary Lou Appollonia, residing at PO Box 850, Saugerties,.NY 12477, my attorney(s)-in-fact TO ACT ~~ ' IF 110RE THAN ONE AGENT IS DESIGNATED, CHOOSE ONE OF THE FOLLOWING '1'\'/0 CHOICES BY PUTTING YOUR INITIALS IN ONE OF THE BLANK SPACES TO THE LEFT OF YOlJR CHOICE: ( ) EACH AGENT MAY SEPARATELY ACT. (__J ALL AGENTS MUST ACT TOGETHER. . (1f neither blank space is initialed, the agents will be re((ulred to act TOGETHER.) IN MY NAME, PLACE AND STEAD in any way which I myself could do, if I were personally present, with respect to the following matters, as each of them is defined in Title 15 of Article 5 of the New Yark General Obligations Law, to the extent that I am permitted by law to act through an agent: ~, . ' o IREC~l ONS : Initial dl1 t~e blank sp~t~~.the I~t~ {r jn~:.-&t~~i~~' one or j~lOre of the iollo"vingll~Jipred~l~divi.sio;:1S as to which you want to glvc agent: authOrJty.iM.'I';IlUit~....~ei~. ...let}w "m', p..'1ftJc..:lar Iet":erp.d' '>:thd.JVISIOI1 .1. S n..ot initialed, no authority will be granted for mnttel;s that,. incltjled in that subdivision. Alterw':ti;~e.lr"A~t If1!tI' corresponding to each power you wish to grant may be w(i~or rype.d on the bla;* line in subdivision "(V)" in ordi:~ tb grant each of the powers so indicated. ; : . chattel and goods transactions; L---> (E) L---> (F) business operating transactions; L-j (A) real estate transactions; L-j(B) insurance transactions; l---> (C) bond, share and commodity.. transactions: . L.__) (G) C___) (H) estate transactions; claims and litigation; (____) (D) banking transactions; Rusk Wadlin Ht:pPIl.:r & 1>1:~rt1>S';.~llo, LLP . Attorneys-At-Law 1.55 F.air Su.'('t, PO '<t., :;35(,. Kingstull. NY 12402 C__) (I) L-J (1) l--> (K) L-.) (L) L-J (M) L-J (N) L-~ (0) (__HP) personal relationships and affairs; L-J (Q) to make transfers and additions to any trusts created by me; and to create trusts on my behalf and to fund such trusts; complete charitable pledges; statutory elections and disclaimers; Social Security Administration, Medical Assistance (Medicare or Medicaid) and all government benefits or entitlf:'"lTJ,;:;nt-,. ull and unqualified authority to my itorney(s)-in-fact to delegate any or all of the foregoing powers to any person or persons whom my attorney(s)-in-fact shall select; EACH OF THE ABOVE MATTERS IDENTIFIED BY THE FOLLOWING LETTERS: A.B.C.D.E.F .G.H.I.J .K.L.M.N.O.P .0, R.S.T.V. My attorney(s)-in-fact shall be entitled to reasonable compensation for acting hereunder. benefits from military service; records, reports and statements; L--> (R) THIS DURABLE POWER OF ATTORNEY SHALL NOT BE AFFECTED BY MY SUBSEQUENT DISABILITY OR INCOMPETENCE. retirement benefit transactions; L--) (S) L--.J (1') If every agent named above is unable or unwilling to serve, I appoint , su.ccessor, residing at _, to be my agent for all purposes hereunder. making gifts to my spouse, my children, my children's spouses and my more remote descendants, and parents, even if such a gift is to my said attOl'l1ey( s)- in- fact; tax matters; [" To induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of this instrument may act hereunder, and that revocation or telmination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocationc.>r te.rrnination shall have been received by sllch third party, and I for myself and for my heirs, executors, legal represem:ativesan . s, hereby agree to indemnity <;nu hold harmless any such third party from and against any and all claims that ird party by reason of such third party having relied on the provisions of this instrument. all other matters; v:----> (V) THIS DURABLE GENERAL POW:SR OF OR ~Y MA Y BE REVOKED BY ME AT ANY TIME. /' ")1,\.0 In Witness Whereof, I have hereunto sig d my name on this~_day of 3.eptGutber, 2008. ep~g~ to make loans and forgive debts; YO" ,,,gn he~ . - ,,':U..J~\LAIi~~HE;LO, SR. STATE OF NEW YORK 00eNTYOF~\J~'~'~ ,.* ,,~ 2.,.(J , l)~e~ ,.' . ....,'. . . ' 0)1 the _ day of ~ri'n the year 2008, before me tlte Ulldersigned, a Notary Public in ans &.lr said ~ta~, personally appeared Alan W. Shevlo, Sr., personally known t<flne or proved to me on the basis of satisfactory .evi~nce to be the individual whose name is subscribed to the within instrument ana acknowledged to me that he executed the same in his capacity, ~nd that his Sl'g n, ature ,on, the., l'n strum ent, the individual, or~' " erson upon behalf of which the individual acted, executed the mstrument. 'J Nf)~:;~"~l G HJ:::po~J!':-R ___ ____ ~ O .:;, I . ubl1r: o~ i'J"w V""k 'Ne') Ih"f"'d I (II ' " ' ,'h -~.< rl ....stp,r :::Ollflt IV, rr. . ,Na 46:}, W17 ' Y ~ -' l,'r'm'~~.'f)n Fvni,..".... ',' ,., . ,'. I.O"''1'1r" ~1. t..oll Rusk Wadlin Heppner.it M~ttisccUo, UP - Attomeys-N-Law 255 Fair Slre~t, peJ"Box :n%, Kingston, NY 12402 J v ,\1., -m- - i ",. , " TEACHERS' RETIREMENT SYSTEM OF THE CITY OF NEW YORK 55 Water Street, New York, NY 10041 · www.trsnyc.org. 1 (888) 8-NYC-TRS 1)e~~~ ~j+ June 21, 2011 TRS Retirement No.: T0982780 0f\1+ g Alan W Shevlo, C/O Mary Luo Appolonia POBox 850 Saugerties, NY 12477 IMPORT~l\IT NOTIFICATION OF THE REVIEW OF YOUR PENSION BENEFIT CALCULATION UNDER THE PER SESSION PAY CLASS ACTION SETTLEMENT Dear Class,Participant: Weare writing to notify you that we have completed our review of your eligibility for an 1 additional pension benefit under the Per Session Pay class action settlement. Your Individual Determination . Employer records show per session wages received during your applicable Final Average Salary period. Therefore, you are entitled to an increase in your pension benefit. . Your specific rights under the Per Session Pay class action settlement are described in this letter. In the spring of 2007, you received a Notice in the mail about the settlement of a class action lawsuit concerning per session pay and the calculation of monthly benefits from the Teachers' Retirement System of the City of New York ("TRS") for retirees and vested members (or their beneficiaries) who retired or stopped work before November 24, 1998. Please refer back to the Notice as you review this letter. If you do not have a copy of the Notice, you can get a copy by going to the internet website for the settlement, www.persessionpaycase.com. or by calling the special Per Session Pay Call Center at 1 (877) 345-3707. As part of the settlement that was approved by the Court in September 2007, TRS has agreed in certain cases to increase pension benefits of eligible TRS members who retired before November 24, 1998 by accounting for certain per session earnings which had not been included in computing pension benefits. Pursuant to a document dated January 20, 2010 that was approved by the court on February 23, 2010, the settlement has been amended with respect to certain limited circumstances defined in the amendment. The purpose of this modification, which is explained later in this letter, is to more accurately reflect per session pay records available prior to November 24, 1998. 1 This notice concerns only the Per Session Pay Class Action Settlement and not the 20 Year Plan Settlement. ~ .... NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for CoeY of Marriaqe Record i:<41~:S~~il~f~~><""~.~.:':. .~; 8,,' L,~~~;C:~ ...,.) '. "'. ,,~:':. "\:. . ';.. ~",:,,"';~:.,;.:)"~!( "t:f,<~t,">J z,>W~~';'::1..,.;..~..;..<~";:::.@.:.::^'V ~.... .'" ',' .. ..'... 0.--'" ".. . " " '.:- h'" ... .~ . :....:>.::9.:.......... .. .,;< <:"".. .:};;.y.~,;..'wr. Search and Certification D Fee $10.00 per copy A Certification, an abstract from the marriage record issued under the seal of the Health Depar1ment, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride end groom. A Certification may be used as proof that a marriage occurred. Ses'ch and Certified Copy D Fee $10.00 per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passpor1B. veteran's benefils, court proceedings, or settlement of an eatate. ~2~~.;:B!;~<~:;~C;: ,',: : ',,/c..n~\, "\.' "".' , ,': ., '" /:', ...f.~~5~.~(~~1~~.2::l.;:::@tr~:~~.~~ (~~) (Last) AlL~~/Af~ (State) AI For what purpose is information required? P~Il)> f'H/ S ..DOC,. U Iff UlT 1I'0t(. r+ j7tfSS,ool<r Af',Q({~.4""';c:JP In what capacity are you acting? SIfL.F N8me of (Middle) (Last) 1i*1KIi: (State) What is your relationship to penson whose record is requested? If 88If, slate "self.. . S tt'-F O~ It.!. 016 II PIea8a print name and address ~ record is to be sent / WOo)} t...1rtJ.b ../)I</V #- /II €-IA..I ,o~ 72-, ~ '(; I II- . /A/W (PLEASE SEE R RSE 0 ~ OC111\ 1.0\\ WAPPINGER "OWNO~N C.b-~~\< ,. -'- DOH-501 (3/95) , ...;;...- J r ,- . NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Col!)' of Marriage Record t.~;4:{1.~,;.~)~~;i~.X~: .... ~ :,~ ;'.'~;."::;~ ~ '. . ~ ~ ",,~~\.:.:.~.:~::/ :TZC;'::~l: Search and Certification r\":::t Fee $10.00 ill per copy A Certification, an absIract from the marriage record issued under the seal of the He8I1h Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. S8fRh and Certified Copy D Fee $10.00 per copy A Certified Tnncript includes all of the items of information occuning on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: pasaporIs, veteran's benefits, court proceedings, or setIIement of an estate. 'J }:~1::ii4:~;f"~:'J ",' ..: " . ."...... . . ". ~ ~$~~\J~~:':.J.:-:t'c:;:'~:0::SI:'~}J_S ~s yo (County) (Slate) 6- l'\~ ,-23-20\\ In what capacity are you acting? -s-etf - UfcA~ ")P~u~ f~~".f f">-t"N- G~^~ ' ,~..k s Name (Fnt) of Bride C Pr(2.o Bride's Age or Date of Birth Residence of Bride If Bride Previously Msried, Stale Name Used at That TIl'I18 Place Where Marriage Was Pertormed (MidcIe) ^"'t-l. (Last) H€Hi~~u t-1 31- (County) A-~e- (State) 1-4 If atIomey: Nm1e and relationship of your client to persons whose marriage record is required. t~'../~,{\:;'; '::Sf.'.~ ;..:.. '. :.">> ~ . :' . : .'.;u'"".: .";'.:.:..,-:..< "h~j:.::~;hfr!. Signature of Applicant DaIle J~ ~ ~ 2<;"lvl Address t Please print name and address where record is 10 be sent \L.\~'2. 'Bo..rtoV'\ ?\Ace 'L>r. -:JAS Ot--l -r: 81lover "-1'=7'1- BeA.r~n I'/~ ~ "D/'. t"), k N e ?. ..., V:K:J ~ 12 I ,I""""', \'. ~ ~'C-S l j. t!f:,1 ~I "'" N c "2 '\\\Of\ GIL./ "'" ~~':-v. ~" (PLEASE SEE REVERSE SIVf 11. \' J.-I A A lL '" ~ 9TA.1t. ~ \ (j.4) ~Comm, Exp, : ; Z Dec. 22, 2.014 ~ \. ~ ,/)VBL1C CJ"j -:.1-~ ~..:- ',," '..... """.,POUN\'t \"..,,, ",'......",. 00H-301 (3/93) - , Of\\VER L\CENSE 1182951 _~'ft; JA60MiA't\.~' 8RooK6 629 DAMlE\.6 6I ,yf 8 ~------~~-~-- sr." ~~;III&: . F :x~ ~/ Clri~ ~ -------- ~ a)/ ._~ ~ T- ".~')r~n.- { ------- ------ ----- -------- -- ---- --- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coe.v of Marriage Record Search and Certification Search and ~ Certified Copy Fee $10.00 . per copy A Certified Transcript includes all of the Items of information occurring on the original record of the marriage. D Fee$10.00 per copy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. _v.<<....<w~...;.;....::{--:::~:.>>:}...::..::~....~.:.: ......w.r::.y::..M~~P....;;'-~.~<-<5.~;...;>'..:.;..'<<-%e.;~<=...~~...,>>.:'\.<;-::-:~y~..<<:':./~>>v-::X:-::-:>>::' "<':::}"N/.~.%:::-:;':::';;::::Y.___ ::~:$::::~::/t'}~i:::::~1: .;\{1j~~ 'j ;;:' ..:. ~ <; .::. '1~' -;>~ {~:: ::": t : ~: :: :"{~ :,' ,. ;. '. : ... . ;:;. -: ..;" ~ :}..f ; :..~~.. ", ~}~:.:t ;<.:: ::~~~~-:::~~~"W ~~i$.:W':~W'mw~x@;,:;:,<<,:,-:-<}:,<<",;";",:Z:<<.....::V.,ry....,.!fj,y / ^X' ,'F.. >>...<: .-:... '. ....::M-:..-;.;<<>>:::-/.. ......:.;...:--/....:..:>...;......<>.. ,,:=::,':VXY>>...;:-;f.->>:O}~.....\.~ PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (FIl'8t) (Middle) (Last) of ..----1' ~o-~\\ ~A-u;: ~ of ~I/-e..."'- ()~~: ~e:' SI,M.~ Groom ItS.N Bride Groom's Age 11'1 I 72:> Bride's Age lo)9f~l or Date of or Date of Birth Birth Residence (County) (State) Residence (County) (State) of Dv~s,> IJ of :t>~ ~ Groom Bride ~ Date of Marriage /0)/3/01 If Bride Previously or Period Covered Married, State Name b Search Used at That Time Place Where Place Where Ucense Was Marriage Was S\. tJ.1.\"'1 > I Issued Performed For what purpose is information required? Dc.lo{lcdfe . I What is your relationship to person whose record is requested? If self. state "self: 'Sf<. \Q. In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Address of Applicant / 5(~ Le 1M. c--I" 'PovCl~St'f- JJf /ZbO? DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for CoeY of Marriaqe Record _~>;:v:..y......., 7>:<"'~:-<<';"''''''~~'N...........:.........y3:t~'*''''-:'Y':v.' ..z...... / v;:-.-" ~. ....:-:..x ....")-. ...... .0'%....0:-;::....v?... "NZ..:-:.;V...>>......xo}...<<<<<q~_ %&;d~!fM1fm4:;;;;)..;:..:~~~....::~~:~~~:~..h ...~..> .~~. . ", J.~.<<\~~~:~ ~.. 'v~~ 'l~; ;...: ...~;..~>>..?:...~~:;f.~,~:~~~l~~df_v&_ Search and Certification Search and Certified Copy ~ee$10.00 M per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. D Fee$10.00 per copy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. _m-~:.X'"NX.........X""-.V...:->.... IX'...'........ ...... ......x.........., .......",.......:-x... "'N.-.~,.. " ' . ~., ..,.....-.-.x".-"..........,'-. .......x..u......N.....';o.... ...._'$&1''*'>>.-=_'' =:<<{..;;:;;;;;:<:.;'<;O'>>-: ..-:..... ..--:.;..0;-...........;-.... n....... "N'" ..... _..V ......o:;>;..~._.. " .....A ,..'..... .. '<- . .......... ~ "'/' ..'^^ ........ ..... .......... ........... . 0{'" :"X" .~~"'=~m 1L..:t%~0i1[i;*.k1a.0;: .:':~~..~\:.>>~~1~~:i:~~~. .......:..4v7 ;~~..\ .;~i.~ ....:.~. .;.> .~.~~:.~...~. ...~:.~r...;;^ ':.~: -::;:.;:€,.~~~~?;;~J;j~ k~~2fM (Middle) (Fnt) (Middle) For what purpose is information required? .:O?~& (~~ 0- (: A t~l~nsl2.- In what capacity are you acting? V\Ihat is your relationship to ~rson whose record is requested? If self. state -self.- c:; L \. ~ If attorney: Name and relationship of your client to persons whose marriage record is required. ~ Address of Applicant . . CAley ~--~~V~\~~ ~Lk- Pt\0v~~'rrr M 1~ DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) y I~ ._/ - 'I /8l/ JIf i _.LdY ~ ) c;'7,-? h otc~t2cf!- , Ii' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe)' of Marriage Record __'::I;i,3t~0~t.%t~~:::::,,;,:~:r"<:,:::'<:.: .. ,,~:. .. . . .,.:.. ~'~,~'~~:.,:::.,:,:.~.'::',,'c~.::r.:~D%.CC::;~~iti.~i~tit'l:_ Search and D Certification Fee $10.00 per copy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and Certified Copy rJf Fee $10.00 U per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or setllement of an estate. !&&__1'l.%;:'~;'::,:i';:: .~,:Q;:S:;:.;:~~~r~~^~: ,.'::' :>~> ~"c~~~y .:,<:,~:;T;"',.'~"c:, ^,":~~:'.::~":;>::'.:. '~' :.'::':~:..^~ .:~~',~!~E:.JtT_\!~t;t.!_m_~ PLEASE PRINT OR TYPE Name (First) (Middle) ~room ('vtd",C\ e I V l'f\~{ Groom's Age _ / or Date of 5) '::J / 1 Y'~ Birth Residence (County) ~room D\J\--k ~ S r Date of Marriage ! ! or Period Covered b a-r ~ol \ Search :J Place VVhere =was . VVu..efi'\ay:> ~ \ \)J rv~ (Last) ,'111 (State) NY Name (FII"St) :ride fvt P\ ltJI' Bride's Age or Date of Birth Residence (County) :ride l7 V\ --k k J.) If Bride Previously . Married, State Name X U8ed at That Tme Place Where ~::as N 0('1\ ~ Y (v\(" 1A)t ) rv y (Middle) C 1('2D1h>>+~ S/ l'dIl~Yb (Last) V](' LtC! (State) tJy ~~~~~tJf::*t;;~0:;:~:rj~I!~7>.,' ~ :".',. ; :Y:;,E~;:.~;^ ..~ .::;.: :'~.,';.::., >.::, .::.' :". .:': . "'.. :: .': ;'.::;' ~. .'. ':,'" ::~~.', .":'::"? ~;:'.<:.'i"'\~;~~~'V;~;;~~:~}f~~;;t.ff~:::~f4:~ For what purpose is information required? C uf Y ()etc1J }:,r V{!:;OI\\ r'r:!V\.Q.. \~~e .--\ r t:Af'.) In f ~.s . In what capacity are you acting? G r oO,'v\ S~~ 11 Address of Applicant 3 Due- \~i\ W ~\J'~(js ~\~ \ N~ DOH-301 (3/93) \/\/hat is your relationship to person whose record is requested? If self, state "self.. SQ \.t: If attorney: Name and relationship of your client to persons whose marriage record is required. x:: Date ID / G-I dsJ\ \ Please print name and address where record is to be sent 3 DoQ \lCl,\ l\~~ ~\h j tJy \ d-~OJo (PLEAliJE SEE REVERSE IDE) OCT 1 2 20" TOWN OF WAPPINGER TOWN CLERK I r ~ Office of the New York State Comptroller Thomas P. DiNapoli New York State and Local Retirement System Employees' Retirement System Police and Fire Retirement System t 10 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.nyuslrelire October 14 t 2011 Town of Wappinger Town Clerk 20 Middlebush Rd Wappinger Falls NY 12590 In reply refer to Reg. No: 13843974 Dear Town Clerk: Enclosed is our check of $10.00. We request that you forward a certified copy of the death certificate of Anne K. Vorndran, Social Security Number XXXXX8442, who was born September 17, 1924 and who died December 26t 1984, presumably at All Angels Rd/Myer Corners Rd. Mail addressed to Anne K. Vorndran at All Angels Rd/Myer Corners Rd, Wappinger NY, has been returned marked "DECEASED". Anne K. Vorndran was a pensioner of the New York State and Local Employees Retirement System. We need a copy of the death certificate to properly close this case. Very truly yourst _./.7. c:X.'(/VL~A.-' C ,--.)J--I.~,~qJ- Linda Doherty Employees' Retirement System Examiner IV LD/Rt278 PA538 / NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for COe)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased }b~l(ph 5 First Middle Name of Father of Deceased o ({) ("'! ('I or<.. Last Date of Death or Period to be Covered by Search 1I/1L-// J1 Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last Date of Birth of Deceased Age at Death First Place of Death '3 I A C\ I P""'! O(? Name of Hos ita! or Street Address Purpose for Which Record is Required Q 0 \, ~ l. St'\ve A., ,:l\'6' What was your relationship to the deceased? 1'1 C ~ In what capacity are you acting? -:::It''\ ve ... ~ ,e\'" \ if'" \ If attorney, name an:;:~o~nShiP of your client to deceased Signature of APPliC~ ",oJ .. Address of Applicant tvYSf 1..~~fP-r Ni..a I~ r;. ~J k\-.~l)'" e,\ Middle Last Month Da Year WA(J!":CNc;<.l"-. ~y Q,A (. \-,t h Coun Date flY 20 { II 1.j~~'1:.""~ _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coer of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. NBRe of D~ceased \)wl"l\. -\' rY'1 First Middle Name of Father of Deceased .-"'" \ Di.v",.l"'l>\ Last Date of Death or Period to be Covered by Search 6/~~/'\ Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last First Middle Place of De~ / 'i f""{I'.l'^$""-(... Dn. Name of Hos ital or Street Address Purpose for Which Record is Required Ql'.lLI..~ S~J{> ~\..\ F>.""~ Last Date of Birth of Deceased I I , if 1"3 I'" Month Da Year Age at Death W ,,~FLIv(,(Z Villa e, Town or Ci 6~\ O..:t. Lzor) Coon In what capacity are you acting? If attorney, name and relationship /. ~J Signature of Applicant Address of Applicant u..{~ p What was your relationship to the deceased? ()cit-. ~ .~ I :J.."vt;) t\'1A hI" your client to deceased J ~ (l') I tlJ.~\h Date [2J 1..J~",p..!:.~{<.. 10/7.\.JIII - Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record .:::t-=::I!!_I:::_.;::Ift!:!e:;::;:;:;:::::;;:; ,.::~:::~:.j!\il!~~"":::J.::;'" "::;:;:::::;::::::::: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased fYJ.f\g, '1 T r\) Q c.J~ I) f\ First Middle Last Na'f' of Father of Deceased Social Security Number of Deceased ~e,' c.k Middle ~~~~() \ \ ~ - \ (; 0 Maiden Name of Mother of Deceased . l"Y\ L Date of Birth of Deceased \4eJe.<"'\ ~ , "\l,'f/)~ N)~I 30 \4&5 First Middle Last Month Da Year Place of Death ~ 13 F- \e~t>cl +--''2 \ \)~ Name of Hos ital or Street Address Purpose for Which Record is Required ,. . " , , , .. , . . . . . .., . '::: :~. " ',: ;::::. . . . Date of Death or Period to be Covered by Search \.\J~~t' \~~e\S fi\))s \0 '} Villa e,~own or C' Age at Death '7'd l)~tJ...Q 55 Coun , \0 S ~ ~ CJ n ho "-\s '""- What was your relationship to the deceased? 'D~\-\.~ -r--€ ( In what capacity are you acting? J)f.\4~hte;- (j If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant _ Number of copies requested with confidential cause of death . Q Number of copies requested without confidential cause of death OCT~ i 1 20ll State~' '\0\ t Zip Code idS9 0 DOH-294A (6/2000) .; f" NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ".r- 1\ tffJ '211 .'jJjANS 7 Hu{Vtij) UO~O~ First Middle Last N~e of Father of Deceased L ,~O---) , f0oPLTS~ Filst Middle Last Maiden Name of Mother of Deceaseq lJu DQa--j P;l.t/OP /' First Middle Last Place of Death 6 bib P r< IItL 1i. G j Name of Hos ital or Street Address Purpose for Which Record is Required ~ ... . . . . .. ,- '" .. '::;;.;:., ..::::::. Date of Death or Period to be Covered by Search 10 / 3 )0 L / Social Security Number of Deceased o r;;'1- 80 ~ 56 '1J Date of Birth of Deceased ~ <" il 6 Icr~~ Month Da Year Age at Death d-> c (~(,L;I? tJ('C c04Pgrcr;,lj/J {-19/I> Villa e, Town or Ci Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant 6(~~~//"~ Address of Applicant Date IIJ- ~o -. JO II ~ Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) State 0(; NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section .... Application to Town/City Clerk for Coey of Marria~e Record Search and Certification ) I~ I Fee$10.oo per copy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence atlhe time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and Certified Copy D Fee $10.00 per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefi1s, court proceedings, or setllement of an estate. (PLEA~l ~~'sE SIDE) - APPINGER ,.O~~: CLl~RI< (County) Uft~ W (State) t()\1\q Forwha~1 ration required? In what capacity are you acting? DOH-301 (3/93) Name (Fnt) of ,_ Bride L--Vi U~' L,t"'\. Bride's Age or Date of Birth :esidence ~CounM Bride \..J u ~ 5 If Bride Previously Married, State Name W '--f Used at That Time I Place Where. (' ~~Was ~+ hshk\\ \ 01-1\ \ I (Middle) (Last) ''S 5 tv' c.cl! vc..,.{....,1<) 9 ~l ~ 'L (State) V\Ihat is your relationship 10 person whose record is requested? If self, state -self: If attorney: Name and relationship of your client 10 persons whose marriage record is required. \~ \, ~\ ~\ Please print name and address where record is 10 be sent