2011
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for Coe.y of Birth Record
Middle Last n
, Date of Birth L.QJ}J ~ ~
Name \J \ \ ~ V. \c,",e - L,,\Yj{1 M M D D Y Y Y Y
Place of Hospital (If not hospital, give street & number) (Village, Town or City) County
Birth :-.J 1 G ~l) \ \'\ ~o06 .\\1 CA
o Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
o Other (Specify)
First
Father Q
\ '\~ ~CA. \r..
Middle
Number of Copies Requested
Purpose for Which
Record is Required
(Check One)
Middle Last
~ \ c.\"\ e \.1
Last Maiden Name First
C-'\ '0 ex f) \/ of Mother \Ie (\ \ \0...
Enter Birth No.
if Known
Enter Local Registration
No. if Known
o Working Papers 0
o School Entrance 0
ICl Driver's Ucense 0
o Marriage Ucense 0
Welfare Assistance
Veteran's Benefits
Court Proceeding
Entrance into Armed
Forces
What is your relationship to person whose
record is required?
00 Self 0 Parent 0 Other, specify
Telephone No. (l.lttQJ) ~~
Social Security No. ~-l1llJ-~
Signature of Applicant
( 0CeVi\\e.
Ci
State
DOH-296A (11/94 ) Page 1 of 2
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
Date
lUc2J lct1I \ \
MM DD YY
300 L13
Zi Code
Town Hall of Wappinger Falls
20 Middlebush Rd
Wappingers Falls~ Ga 12590
10/07/1 I
I Rajah Ghany being dually sworn. I have known my daughter Venija Iesha Richey-
Ghany ~bom 03/28/93, in Wappinger Falls all her life~ and she is who she claims to be.
.cJ ,-" ~,,~'"
~"j~
Rajah Ghany ~
1225 Shelton Way
Lawrenceville, Ga 30043
\Jpwr ~.
':;)rf L
(VI J (O)IN"^"< S SI OY'--
1/3;11)"
c'
III ~~..
~>r I 'r("..s
""....",
...' €,KA M. 'I,
_,'tlA..-{' .... ". .c~'.'.'
... -, ... - ,
...... ~ """O1:~" '
.. . l' ."
..- . ",
.. ,,~~-~J,.,. :
. .' ~ .,-
-. Olt ".
:~: """'-, c,..: :
· Z. . I.. ~. ..
. _. ~ ' -I, · ..
.""1' ..
~~'IJ.:. I.tC~'. !t
'W"".~"." ...'
~'i':.' r co ,"
'I, , ",
,'...."
~(7
~.u.tJ 11_
(;CU.UGJ;
CL-AW
CAAD
012 =
BC# P "42264
. i. 'i,"RrN<:Z:'.~;i~,Lr, ~;.~
')":.{) '.;:,
iII"..iI.~'
"" 1111;'
LL\IOes.'.. (HAFFJ;'Ftn i'ER\UI
.,\,\1E: R}\,.j:~H r;UAN\'
HR\iii:o: G'lU560
!.'H")B: 06/12/14l()(~
\';'..\FD C16I(,'7';WHI
\.P-\R[~,: {ji}/07/2614
,
!'/ ~, lifl~)~
"~~.---"'-
CO'~1\!l""'I()"[R
~
,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Birth Record
o Passport
o Social Security-Retirement
o Social Security-SSI
~ Retirement
o Employment
o Other (Specify)
First Middle Last
Name aX .)3 J/IL. ~ 11 I. ,;
Hospital (If not hospital, give street & number)
Place of / () 6 rn fM-/4- - --;-: (~7
~~ ~ .
" u jJ.'. Jd-6 "'f 0
Middle ,nSI ,
(') . ! rf /1/--1
F t
Fath~
~ oil ~
Number of Copies Requested
/
Enter Birth No.
if Known
Purpose for Which
Record is Required
(Check One)
What is your relationship to person whose
record is required?
L81 Self 0 Parent 0 Other, specify
Telephone No. (t1Jj) It.bl.J tLlclf..ill
Social Security No.el~tJ~-~
ddress of Applicant
fi If,l/w;~ ()/Z.
Atreet . r-! /
J-J. uC;Ht:r,{'r!JL 1-" ~ .
Ci I State
I J..-bC -3
Zi Code
DOH-296A (11/94) Page 1 of 2
Date of Birth ~ ~ ~
MMDDYYYY
(Village, Town or City) County
Ql~Af~ S
,. r-
'M I ~ J'HLLs
Maiden Name First
of Mother
Middle
Last
/C{;~61L
(.:-
Enter ocal Registration
No. if Known
o Working Papers 0 Welfare Assistance
o School Entrance 0 Veteran's Benefits
o Driver's Ucense 0 Court Proceeding
into Armed
~~M\\n~~es
~lE~~~u '!j ~l1dJ
(name of client)
(relationship)
:.::;:::::::: ';:":::::::::::':'''-':::'<;';:;:::'::1' ftIl!li::~R' en,' ......6:.:D~S. .1':.81':"10.:::"':::':':::;'" ....:..
........ ........ .......... ~. KU *":~.~::nMnr '* .W.~IiiiiC::I::: ',',', .,' . .'
, "
v
;-
~\.. SECu:
0' :,p....
~~
\ 1111I11 ~~
l\rISTv..~
SOCIAL SECURITY ADMINISTRATION. POUGHKEEPSIE, NEW YORK
332 Main Street
Poughkeepsie, NY 12601
Telephone: 845-405-5349
July 13, 2011
Town of Wappingers
Town Clerk's Office
20 Middlebush Rd.
Wappingers Falls, NY 12590
Attention: Town Clerk
The Social Security Administration needs to establish a date of birth for SSA purposes. I am
requesting a certified copy of your records showing the date of birth for the individual listed
below. Enclosed is the processing fee of $10.00 for the requested certification.
Name: Kyle Asa Iwatake
Date of Birth: 4/13/2011
Place of Birth: 6 Stanley Lane, Wappingers Falls, NY
Father: Michael Minoru
Mother: Tara Margo Bernstein
Registration No: 3
\--:"
C...;J
\1 -\.1
rc=v
" ,
, '-.-. " \)
-~~tJ
--
JUL 1 5 2011
Susan K. Holcomb
District Manager
TO' )'d
\,\1
l\lGER
I'
1~
_..._"-'_..._-~.
Application to Local Registrar
for Cae.)' of Birth Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Name ::S:-ohn Sl ~/e
Hospital (If not hospital, give street & number)
Place of
Birth ClQP fiOe...
Date of Birth ~ ~ ~
MMDDYYYY
(Village, Town or City) County
~PP(f\~~~S ~LcheS5
First Middle Last
Father ~ u. m I y\ R11o/kw ~Ii
Maiden Name First Middle Last
fMother 9f>~5 eUIt )Yl1e~
Number of Copies Requested
I
Enter Birth No.
if Known
Enter Local Registration
No. if Known
Purpose for Which
Record is Required
(Check One)
00 Passport
o Social Security-Retirement
o Social Security-SSI
o Retirement
o Employment
o Other (Specify)
Working Papers
School Entrance
Welfare Assistance
Veteran's Benefits
Court Proceeding
Entrance into Armed
Forces
What is your relationship to person whose
record is required?
IjJ Self 0 Parent 0 Other, specify
Telephone No. (~)~~
Social Security No. ~-M~
(name of client)
(relationship)
Signature of APpli,C~
r:z-, :7~
Address of Applicant
,~5 lO~he\'u.Jocx:Y till /
Street. 7 (7'
~/'r J/C7r /J 7- J'L-A1 /{lS 0
Ci' Sfate Zi Code
Date
LJ:zJ lLtJ1 \
MM DO YY
DOH-296A (11 /94 ) Page 1 of 2
J
v
"
~
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe>' of Birth Record
First Middle Last
Name Uorot h' J alt\e- --;\uS's ell
Hospital (I not hospital, give street & number)
Place of
Birth /4 S'oa+h A ve Y1 u e.-
Date of Birth LQ1:2J lQJQJ ~
MMDDYYYY
(Village, Town or City) County
lJl}ttpp i ~ 5 e r'"_S F a-l/s b u.te-h ers
Middle Last
First
Father J 0 k V\
Middle
Loui5
Last Maiden Name First
1+ u. !In In e I of Mother Ma f
)+ j [JVl e/J
Number of Copies Requested
,
Enter Birth No.
if Known
Enter Local Registration
No. if Known
o Passport D Working Papers 0 Welfare Assistance
o Social Security-Retirement D School Entrance 0 Veteran's Benefits
Purpose for Which o Social Security-SSI D Driver's Ucense 0 Court Proceeding
Record is Required ~ Retirement D Marriage Ucense 0 Entrance into Armed
(Check One) o Employment Forces
o Other (Specify)
~"" J CL 11\ e.
What is y ur relationship to person whose
record is required?
~ Self 0 Parent 0 Other, specify
Telephone No. (~) ~~
Social Security No.ldM-UEl-~
Signature of Applicant
~L/
Address of Applicant
/21 ~~ ft.
Street . r- _ 10 tI v
Jl)~~ r(/UJb, .L
c=:--vrv f State
I ~,jq (J
Zi Code
DOH-296A (11 /94 ) Page 1 of 2
If attorney, give name and relationship of your
client to person whose record is required
(name of client)
(relationship)
v