Box 185
Records Inventory Data Worksheet
I::d~ e~r n~J~rn1><:::~1
See Instructions in Publication #76, "Inventory and Planning", Before Completing Form
Government Agency 11 ()W'f'\ \) \ W .",P-{)lY\h{ (.. Department I Of\~G \) Yf't\:V\" .
..-................--..-_..-..........-.... .............,...-... d ........-...
Record Series Title I..'<t>~~"\~t;\\~~~\)m...
.... d .. on. n_.. __ _~..._.. ...._~ ....... ....m... ..... _~..... .._. ...-.. ..........-... ..
(describe content
and characteristics
of records)
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-I
I Date Span
Records Series
Description
C Alphabetical
C Numerical
Arrangement . Chronological
C Alphanumeric
C Other (specify) I
C Not Scheduled Retention Period I. lo ~ {..l..j ~
C Permanent
Retention .....H......_...._........_..._._...~..._.__...... ..-.......--.. ........-. n... .__.. .
C Historic
C Scheduled Schedule # lm~_~\'j_\ i II Schedule I d I
-........ .. ..... .~...... '"' .......--.............
1("'1'0 W ~ \h .......
Location
n__...'"
Format .. Paper C Audio-visual CMicrographic C Electronic I
Total Quantity ('Cubic Feet: C Items Amount: 1 I Type of Items: I
. . m ..
Annual CCubic Feet Amount: I.... uh . I I Items Lm \
Accumulation ....~. .. ---.....,.....
Frequency of Use CDaily C Weekly ('Monthly . Seldom \ICNever
Restrictions or, Use IN/A
Records Are: Ir, Poor 10 Vital (Essential C,Official Copies
C Condition to Operations)
Name of Person Completing Record I \\~ ~ \V\ L- \)"'\.lLL..-.\ ,\ Date I ~-l~'\d- I
J - -
New York State ArchIves
JCM (2011 01 05)
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