The URL can be used to link to this page

2012 , 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. ~~~1~~m1~~@~:~:~~~t~tttmt~~~j~j~m~frj\t~~~t:~r~~~~~~~~~~~i~t~t*~ftfit1~~;~~m~m~j~1~~&@~M~;~l~ll~l~ilil~~;~~~~t1~;;~~1 ~ w:Y:t::::" .:y~;. y' u ~~: "'0""7": Date of Death or Period to be Covered by Search 5-/7-/2.. Social Security Number of Deceased ;~:w~~?:~~~t~;\~?:l~1~1~j~~~~l~~~~j~]~m1&~ir~~~1f~r)~ili~l*~ij@~I~ltn~mili1jr~~~~;~~~~;;@~~tr~~gj~~j\~~~:~j~jjrr:m~l~~1~ Name of Deceased LoRRAOJe. First Middle Name of Father of Deceased !( J (.jj JJ RP First Middle Last Maiden Name of Mother of Deceased J) Date of Birth of Deceased /M-~C-4/let' ~/ / c2 If First Middle Last Month Os Place of Death /I () Ih (, 5' "/t< At L 4 JJ c,e ~ ,; I J.~ i? lJ w.4P/J. rAilS 1J1' /:2.5"9'0 Name of Hos ita! or Street Address Villa ,Town or C' Purpose for Which Record is Required RfJSe/iML Last D I/RJJ!tv/( J/7-'1~- gS7 Age at Death r J9 f") ~ , , Year ! ~ .' , D ()f"c./I-e ~ s . I I t Coon f fie 1~5e.5 What was your relationship to the deceased? J.I (/s LJ// /lJ1:> In what capacity are you acting? Be N'ehCIAA Y If attorney, name and relationship of your client to deceased Sig_ofAPplicam4 p~ Address of Applicant 311.2 1 it. A N6-~ L..f /I/Li- ,AJ D r;t: IV.J rJ RA lie e.- 0/4 Date t-/ f".../;< #41'1'/JI/~&'~5 /:#t-J.~ Py 4- Number of copies requested with confidrial cause of death. 1M _ Number of copies requested without confidential cause of death ~ : :~~:~~~t~~~@~~~~t\mr:~~l~~titmmm~~\~~t~r:r~tf~~~tm~ Name Address City State Zip Code DOH-294A (6/2000) f , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record PLEA_ . ..... '.--.ANQ"eNCLOSEFEE.',", , FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. p"--.;PRIN'J' :ORTYPE Name of Deceased Date of Death or Period to be Covered by Search Rose M. Scher April 30, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Gerard Caggiano 114.10.6332 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Una Saco November 27, 1916 95 First Middle Last Month Dav Year Place of Death 9 Dugan Lane Wappinger Dutchess Name of Hospital or Street Address Villaae, Town or City County Purpose for Which Racord is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. If attorney. name and relationship of your client to deceased SignatureofAppI~~~ Date May 1, 2012 Address of Applicant 8 5 Route 82 . Hopewell Junction NY , .. ..... ", .-.' ".- -.: .... ...:.: ...... . .... ..' ',. .....' . .'. . . ,a._,;~,;: '1..,,18It:.,:,;", .':', :::: ":};:'.':,: -L Number of copies requested with confidential cause of death _ Number of copies requested without confident/alcause of death Name Address City State DOH-294A (6/2000) MAY 0 S TOWN OF WAPPINGER TOWN CLERK ~@ 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. Name of Deceased Lorena G. First Middle Name of Father of Deceased Larry Opal First Middle Maiden Name of Mother of Deceased Elizabeth First Middle Place of Death Elant At Wappingers 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 ofthe deceased PLEASE PRINT OR TYPE Date of Death or Period to be covered by Search Pomatti May 16,2012 Last Gardner Last Social Security Number of Deceased 200-07-1065 Steele Last Date of Birth of Deceased 9 18 1918 Month Da Year Age at Death 93 Wappinger Villa e, Town or Cit Dutchess Count What was your relationship to the deceased? Funeral Director In what capacity are you acting? Funeral Director If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant 1 Date Ma 17,2012 COMPLETE FOR DEATHS OCCURING AS OF JANUARY 1 1988 10 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) Jf- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record '~_'f"'::f]'((f;:(fj:(t::j(:jM'fff:,\,,'(:j:':::::ff'i,ti:ff(:':j")j,; FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. rtnfr~~itt~~t~frr~t~\~~~~ttWr~~ff~~~~~~~~~t1~~~r.~itt~~1~ij*~~~~Hf~~~r~j~~~~r~r~~;~;*ml~lj~~~~~~~it~~~i~~~ ~ ::f:t;;: .~t;T~'" ~~; 'U"u;u': Date of Death or Period to be Covered by Search .::r OL '(') lJIo... ~ I 0) ;;>"'0 08 Social Security Number of Deceased ~J*%l*~;lw~~m;;~1~mrf~~rm~~!~~jIt~~i\~~~~t~*~*i;~~~;;~~~;j?:~1l1~~~~~~~m~ili~f@j~j~~~~~~\t~~~~W~~~f@~~f~~~r~~~j~~:fi1~~ Name of Deceased -- Firs.J Middle Name of Father of Deceased J[)~eph Q,. First Middle Maiden Name of Mother of Deceased R.ro ~ Pe.:rr; () 'I First Middle Last Place of Death ~3 )..,1' S~ Rd. Name of Has itaI or Street Address Purpose for Which Record is Required 3:!h!Y} j cJ Last S<!..hm'\d Last Date of Birth of Deceased Av...fJ \tS\ 11 Month Da )q t3 Year Age at Death q~ iJ.M tIz e. SS Coon What was your relationship to the deceased? D o...u ~ h kv- In what capacity are you acting? 5 v\ ~u..I(-a.. \II....~ r u... "'po Se.-S If attorney, name and relationship of your client to deceased Signature of Applicant ~ y.J. l(i~ Date 5) J 7// ~ Address of Applicant J,3 ~ tJ.. " )u~ *.1 I.L-/ )J \ l' /:J.. 69tJ _ Number of copies requested with confidential cause of death ~ Number of copies requested without confidential cause of death : ::11;j!~~;if:t~~~~~~~~~m~~:r~~tmt~j~~~~jr:j~~@ft~t~~~i~~li~~~ Name Address City State Zip Code DOH-294A (6/2000) w:r- , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record ... >':PLeA;SE;COMPLEl'EFORMANoeNC.LOSt:PEE ,... .,. ,:":"77 FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. L-. ....}'P(;I$ASEPRINTORTYPe'.'.' ......... . .." ........... ...."....,.,.......... Date of Death or Period to be Covered by Search \..-.t~ ~,~\'2- Name of Deceased ~ld First Middle Name of Father of Deceased ,AVliV\cnV\ First '-.J Middle Maiden Name of Mother of Deceased Gnc>\c\ Last .~ rreJ \ Social Security Number of Deceased Last eel - 2-t.t- 3O"?-Lt Date of Birth of Deceased Age at Death B\ L-enCi First Middle .B::r-;-o Last Month Da Year Place of Death ~S. ~erA~ Name of Has ital or Street Address Purpose for Which Record is Required \ .A rf',. . ~JL-t~~~ ..~ Count What was your relal'o.nship to the deceased?J=iA~ ~\ ~S:)'n-c-iz12-' In what capacity you acting? <'Y\ ~~+' = :G.ml ~ If attorney. name and relatl nship of your client to deceased :COMPLETE FOR DEATHSOeCURR NGASOFJAN. t 1988 mber of copies requested with confidential cause of death::)-' Ve.--}e"o..(l 6-:29\.-("'2- Signature of Applicant Address of Applicant . . .:.;.; .:.', :::::::: '. .::.:::';'::;::: ::::< ,'-:':':' :-:.:.;.~. :':'. .>:".... :;;::::.::::::.;::::: "..:.:.' :::;;::::::::::::::::::::::::::/:":: _ Number of copies requested without confidential cause of death :\,PtJ;A$E:PRIN.'tNAMe.:4NO\AoDRe$$.'WHERSJ'1I$CO.RP::$HOU'Cb:ae.::SJ;Nl\::::{)/:n::::: ... ... .....,............. .. Name Address City State Zip Code nOH-?94A /6/2000\ jff NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar tor Coe.Y ot Death Record PI 08&' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. '. '.PRlNTOR 'J"YPIji Name of Deceased Date of Death or Period to be Covered by Search Carol Ann Veltri May 27,2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Pasquale Patti 093-34-5885 First Middte Last Maiden Name of Mother of Deceased Oate of Birth of Deceased Age at Death Camille Uzzilia March 22, 1943 69 First Middle Last Month Day Year Place of Death 7 Heather Court Wappinger Dutchess Name of Hospital or Street Address Villaae. Town or City County Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home of Fishkill, Inc. " attorney. name and relationship of your client to deceased Signature of Applicant -cc>~ Oate May 28, 2012 Address of Applicant 1089 Main Street Fishkill NY . " ."...... ... .... ..._,.~::. .... ................ . '";'''-:';',:' ..', ..::::>'../ -L Number of copies requested with confidentiat cause of death _ Number of copies requested without confidential cat.Be of death Name Address City State Zip Code DOH-294A (612000) ~. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Col!)' of Death Record : i ! FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~1~~ttttt~\f~ttfrjf~~~t~rf~i~~~~f~~i~jf~~~@tj1~~f!j~~~ri@fi~ittr~f~tt~~!j~ii~~~~i~~~~~*~~i~[;i!j;~1~1ji~~ :JTY:t:,.~ ':~:T TO. *"": .......:.,~ ~~~~~fif:j~;~r:fr~~1!i~j~;ij~~~f~f!~~~1;jilif;~~ri~irWr~~jt~i~1jjjm~t1~~t1~11i~r1l~t~1i~i~~1~jt@f~tt~]@1~;~rt~J~jfi~~~~ Name of Deceased CENC-li... First Middle Name of Father of Deceased tV R a" First Middle Maiden Name of Mother of Deceased ~ IV!. I f1-14 First Middle Place of Death S- If/M.U ()(l... Ltr(.L (lclll-D Name of Has itaI or Street Address Purpose for Which Record is Required t,r~ /rtlvc..~ CENC- Last Date of Death or period to be Covered by Search Arl'~ll '-(~ 201L. Social Security Number of Deceased C c'"'1V t:.. Last LENt:., Last Date of Birth of Deceased fL 6 Month Da 1~f:,L Year Age at Death '-I~ o "feLf I Coon What was your relationship to the deceased? f::.r I,) In what capacity are you acting? AJrv..c'7\<l ~ L:/..f (h.J~'1 c.e ~e I>I?fJsc-llC''^r If attorney, name and relationship of your client to deceased Date .. (...... L.. r z... J f>rpl rw t,.€"I- J r- A-l..L& tv '1 (2.Ji C7 ~~ Signature of Applicant ~ 0 Address of Applicant I tJ 4. f:- R d IJ I ftO b I( (r/t::; .. " . . .. . .. . .. " . . .. . .. \. . ... \... ...... . ........;:...... '" .\\ .. . . . , '. .... '.' . '.',". '.' ,.':,.:::::- ..... ':: .... . ':' ":' .... ......'. .~.'.~:..'.""':::';":..':,'.""" ..........\..~.t~:::.:.:.:::.:::~.::'.:.:.~.~.~.~::.~.~.;:~.;:;..;:~.:~~,~::.;:~.::.~.;,:.:::~.::;,::.,:::~.::~.'::'.::::,.::..:::~,!:~,::..:.;.~,::~.;:.~:;.~:'~,~:~,~:,~.:.~,~,~.:,;:,:::'..:~.~.~,i,.~~~,j,:..~.~.~,~.~,:." ~.~.!,~..~~.~.~.~,:.:;.':,:~,~.~,~,'1.~.:,:::;.':,::.;.:,~,~:~.j,~,~,;.,:,:, 'i~;j~t~~~jji~iMfi[~~ii;~i~f~1ii~1~;ii1;~~{j~~iii~;i::ii;11i~im~~;~i~i1r: ....:... ...... ... "f "::"; .. ~;;' :~... .......T .:.......... ':. .:.."., .:.::....... .'. '.' ... '. ". . ~ ~ ..... ..- . ~ Number of copies requested with confid~a1 cause of death . _ Number of copies requested without confidential cause of death : ::1~j!i~1mt~~*=~~~~~1~~~~~J~~~i;tm~~mrttli~f~~~~m~m@ Name Address City State Zip Code DOH-294A (6/2000) w~ " y NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record .'. <'<PL$ASECOMP..J~TEFORM AN[).ENCLO$E:H~EE<""" <,.'. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. . .. .,.".....,......,."",'.. ."..' '>pLeAsE PRINTOR Name of Deceased S~ First Middle Name of Father of Deceased u.V\~ First Middle Maiden Name of Mother of Deceased \.l.h..~ OA'l~ 4 ~ ?-e .. \ 9 2:,9 First Middle Last Month Da Year Place of Death -:::r).....\xY-C\lUu~ 'P\~*\\60 W~f\~~ Name of Has lllai or Street -Address ilia T own or b:tv Purpose for Which Record is Required ~,*\\.k~YS w. ~~ Last Date of Death or Period to be Covered by Search ~\ J4, '2--D\~ (h~ Social Security Number of Deceased \ b4 ... ~ ).. - \ 4 ~L-t Date of Birth of Deceased Age at Death ~:1- ~s.s Count What was your relationship to the deceased? f,A. \.u vu..O cltV~ In what capacity are ~ou acting? ~.f w.*-~..nu..tq If attorney, name and relationship of your client to deceased - Straub, Catalano & Halvey Funeral Horno rm l':ilsr iVlilin Slrcct ) Signature of Applicant I'~; Address of Applicant Wa In ers Falls N.Y. 125 " ~ Number of copies requested with confidential cause of death -t:!- Number of copies requested without confidential cause of death H%CPLeASS"PRINt:NAME'::ANp:J\ODRE$$i'WHER'S:RSC()Rtr$HOU'!:.pae,SJ;NT::::(:)(: ...... Name ~yY') "R1/\!\.e9-.. - .;:re\'\YlE' .\{" Address ~ cec\~r La...n2.. City L-o..ZjC State \-L- ZipCode ~~D DOH-294A (6/2000) vV:( NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COE!)' of Death Record -FEE...',..... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased AWo ~riW First Middle Last Name of Father of Deceased Francesco Zirilli First Middle Last Maiden Name of Mother of Deceased Santa Contarino First Middle Last Place of Death Elant at Wappingers Falls Name of HosPitBi or Street Address Purpose for Which Record is Required '.PAlNTOR TYPE Dele of Death or Period to be Covered by Search May 4, 2012 Social Security Number of Deceased 125-40-5491 Date of Birth of Deceased January 6, 1920 Month Day Year Age at Death 92 Wappingers Falls VlIIaae, Town or City Dutchess County What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home of Fishkill, Inc. " attorney, name and relationship of your client to deceased SignoIure aI AppIcanI . ~ .1 Address of Applicant 1089 Main Street Fishkill Date May 7, 2012 NY . '. . .. ..., ., -L Number of copies requested with confidentiaf cause of death _ Number of copies requested without confidential cause of death Name Address City DOH-294A (8/2000) ~ NEW VORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record ..FEE...',..... FEE: $10.00 per copy or No Record Certification. Paease do not send cash or stamps. Name of Deceased Michael C. Schultz First Middle Last Name of Father of Deceased John Schultz First Middle Last Maiden Name of Mother of Deceased Grace Morgese First Middle Last Place of Death 110 Smith town Road Name of Has' or Street Address Purpose for Which Record is Required Social Security Number of Deceased 132-44-6967 Date of Birth of Deceased September 19, 1954 Month De Vear Age at Death 57 Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home of Fishkill, Inc. lf attorney, name and relationship of your client to deceased sv-emApplcn ~~ Address of Applicant 1089 Main Street"_ Fishkill Date May 7, 2012 NY . ..... .. ........ . .... " '" . .. ..... . . .., . ;: ~ Number of copies requested with confic:Jentiat cause of death _ Number of copies requested without confidential cause of death State Name Address City DOH-294A (8/2000) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COE!)' of Death Record ." NCLOSEFEE'," FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. P~PAINT:ORTVP& Name of Deceased Date 01 Death or Period to be Covered by Search Pilar Siekierski May 5, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Ramon Matos 095-32-7394 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Basilia Marcial October 12, 1940 71 First Middle Last Month Day Year Place of Death 74 Spook Hill Road 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'? McHoul Funeral Home, Inc. If -'ney, name ond '01(4 YOU' c~ May 5, 2012 Signature of Applicant ~ Date Address of Applioant 895 Route 82 Hopewell Junction NY .' . ..............._""'.. I...a"vr:' "1;;,.1.*:.,;.;.. '. ':'.' ::; :',<::::.::,: -R Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death ".': ':SHQULD Name Address City State Zip Code OOH-294A (6/2000) & NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record ..... ...... . ........PlEASE;COMPl,;:E;TEFORMANOENCL.OSEFEE<.. .... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Dec:a. sed ,.i . 1\" ,^.~l L. 'eAC.L. ~~ Middle Last Name of Father of Deceased W\\\'\~ First Middle Maiden Name of Mother of Deceased Date of Death or Period to be Covered by Search 5- 0. c\--V\ ~ \ '\Lt.c e.. Last Social Security Number of Deceased Oq (t).Li d- - <1~~" Date of Birth of Deceased Age at Death b\\v<- First Place of Death \ 16 C)-o~ 'V2o~ Name of Has ital or Street Address Purpose for Which Record is Required '-0Ul W-.\I~' O--~rS Middle f~ ~-LJ-I~~ t.t Month Da Y ear ~ ~SS Count What was your relationship to the deceased? ~. d..t~ In what capacity are you acting? D~ ~ o~ ~'-'\ If attorney. name and relationship of your client to deceased - Straub~ Cafalano & Halvey Signature of Applicant Funeral. .., r::- I' - - " Address of Applicant ,):) ;'lsr Mdin Street I,: Wappin . . .<cOMPLETEFOR DEATHS..bedURRlNG:ASOFJANU.. . S-. \ D. 1.L ..............-...... . . , .. .... - . ., . ............... . ~ Number of copies requested with confidential cause of death -1- Number of copies requested without confidential cause of death PLJ;ASEF{fUN"tiNAME:4NPAtU:)Re$$WAI$ReFtSeORP$HQULO.eI;SI$NT: . ...................... ." .................... ................,......... ...,........',........,.. on ...,.....- .......- ......... ... ..,......... ..... ..................... ,... Name Address City State Zip Code DOH~/20001 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Cae>' of Death Record PlEASECOMPLETEFORM,AND"ENCLOSEFEE'. - FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Lorraine First Middle Name of Father of Deceased Richard First Middle Maiden Name of Mother of Deceased Margaret First Middle Place of Death 342 All Angels Hill Road Name of Has ital or Street Address Purpose for Which Record is Required PLEASE,PRINTOR TYPE Date of Death or Period to be Covered by Search Rosenthal May 17, 2012 Last Durnack Last Social Security Number of Deceased 119-44-8578 Day Last Date of Birth of Deceased January 24, 1951 Month Da Year Age at Death 61 Wappinger Villa e, Town or Ci Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. If attorney. name and relatijSrp of your client to deceased Signature of Applicant ~~ Address of Applicant 895 Route 82 Hopewell Junction Date May 19, 2012 NY 1.":-' --L. Number of copies requested with confidentiaf cause of death _ Number of copies requested without confidential cause of death -:SHOULDBE e ' : Name Address City State Zip Code DOH-294A (6/2000) rex \:) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record ... ...... .el...~A$$~QMPWl$mf$J;:'mal\llANiJl)~NQI1Q$$F:~I$>... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased W/LLI~fV\ D. First Middle Name of Father of Deceased T!-It> t1A 117 First Middle Maiden Name of Mother of Deceased J v Lt Ij j) tJNH !fill? First Middle Last Place of Death A V fIt Lo tJ ,q. ~S;. L /t)/1\J6 Name of Has ital or Street Address Purpose for Which Record is Required .J A rJSE,J Last Date of Death or Period to be Covered by Search S-z1- /2- J 1t1ll5eN Last Social Security Number of Deceased //7-/'- 9o:l1 Date of Birth of Deceased Age at Death S Month 9 Da /9:;3 Year ~<:J w".,oj?, ,vG€1Z V' .D OTCljt;.> S Count 10 SerrL~ ESTI17e- What was your relationship to the deceased? FUNb7Vf( ..l>{~(:-c.7l>4- In what capacity are you acting? S4/'V1e If attorney, name and relationship of your client to deceased Signature of Applicant ::x(, ~ J4.J '~ t1 ,.()~ ./ ~ -L::; Date S - 3 t> -- I 2- Address of Applicant t Lf' €. M 1'1, rJ ST. Ld IJ # / /If ~~ F f1/"1 ~ f -V Y / Z..s-9 0 ...............U.............U.......eOMPLETEFOabEATHSOCCURRINGASilt#JANUARyH198s.............>.>............................................. . ~ Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death ...... ...............<......................> <...................>>pl...~A$ePRJNTt'4AMEANDAtU:).:a: .... . . ............................................."..................................... Name Address City 2l0Z 0 8 A\fW DOH-294A (6/2000)C:;::: 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. ~fttt~:ttrjrtmi:~r~ttf~l1~~t~~t~1t~~~~~t~~~@~i~f;!~M1~~M;ft~~t~~~~~~~f~1~@j*m~~~~i~~~;~~1@~m*~;~j~1 ::JT:J:t;'-:: ":~~"r r"" $~~ """"^:"<': ~$if;;f:?:~;?m~t~;m~~;m~rmm~1~~~~~~tmmm~r~~~~~@;~ili;~~!~~m~~;~~;;!~~~~~rm~~~~rmrm;~~rrrnmm;~mr~tt?t~~~~:~ F/t.OJIV\ Last Date of Death or Period to be Covered by Search 4:' ~ /ZtJl z... Social Security Number of Deceased /Yo ~y()-" ro 'fr- Date of Birth of Deceased Age at Death Name of Deceased 5' Tv /'f'It.-'/ First Middle Name of Father of Deceased rc,cnJ Fi~t Middle Maiden Name of Mother of Deceased ~~~ I~^y First Middle Last Place of Death I j"p,e./Js'/'-"<- #1 V-J- Name of Has ita! or Street Address Purpose for Which Record is Required ~Q..5 ~ ( FaOr1}/)1 Last Month Os Year 1v k-kJS Coon What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship ~c.Jn.e 1"'- ( ; tt.e.. c.. ro Signature of Applican Address of Applicant W - I J' 0 <'R/'1IZD /2. I D Number of copies requested with confid~tial cause of death _ Number of copies requested without confidential cause of death JUN 0 4 20\2 TOWN OF WAPPINGER .. ,...__ ~.~_,,~ _. W'_ . : ::;~~;~;~;~~~~t~~;i~1~~[~~~f~~~t~Mm~t~~~jfft~~~~~~~~~~~~~i~ Name Address City 5~Oe.Wl.s. W- ISO P(ll,'4ff\v <". /-1~Vl'Y'- L /2. r JI C ~A.fJfL. / State NT Zip Code ol~:;:<-' DOH-294A ~) " NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Col!)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased HA~((\ JJATAL--(~ First Middle Name of Father of Deceased S Fe~rJlL. First Middle Maiden Name of Mother of Deceased ]-1(0- )!.C!..E <; t) 4... (2b 5 r:'~ First Middle Last Place of Death,O E J ~).< r.C1 V'te- . Name of Has ita! or Street Address Purpose for Which Record is Required ~ d c9)< ES Last Date of Death or Period to be Covered by Search :~h?J@f:~lli~l:;~~?l~r:~1~mm~rf~;~~;i~~jililfU1~~~~jf:~~~~;~~f;~~1~~f~~j~~111~~~j~@~1~t~~tft~~1t~~t:~~rm@r:~~~f~~t;~~~rm r~r:~f~:rf?t~tti~fi~if~~ftF~t1~~~~@~f@@~~~~~jjt~jjri@~t~~1~1tt~1~r~1@~i;~~~;~;~~~;1~1@[i~~~~~@11. '.J1fF :;o~ o:v~oT '1,..0 ~~~ ""-:~",': ..1-~.9,9 (qq"D ~ Social Security Number of Deceased Cs-f~'1\4 {\ Last Date of Birth of Deceased { )... 7- S- Month Da J-.9og. Year Age at Death 89. yvt. Coon What was your relationship to the deceased? SffYt In what capacity are you acting? If attorney, name and relationship of your client to deceased SignalureofAppicant ?""y../, f~ Dele 4fl/':2<PIZ- Address of Applicant 8 ~(,CA.~t~ 5f ~ ~vofr~s/a; ~y JZ-b03 ~ Number of copies requested with confid~ntial cause of death ~ Number of copies requested without confidential cause of death : ::ili~l~%~;1~;~~~~~~fl~j~tt~1~~m~j~~~~~ttt~r~~~~~~~[~~~ Name Address City State Zip Code DOH-294A (6/2000~ xnY. . -:' i , NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 I Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for traveL) A. One (1) of the following forms of valid photo-IO: -OR- B. Two (2) of the following showing the applicant's name . Driver license and address: . Non-driver photo-ID card . Utility or telephone bills . Passport . Letter from a government agency dated within the · U,S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Vasuben C. First Middle Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Shah 083-68-9045 Last Date of Birth of Deceased: Age at Death: 06/03/2012 mm fu Maiden Name of Mother of Deceased: 12/27/1933 78 mm / dd / Death Certificate No.: (If known) Samratben First Name of Father of Deceased: Mangldas Shah First Middle Last Place of Death: 28 Carmel Heights Wappiner Name of Hospital or Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Tot~1 number of confidential cause of death I confidential cause of death copies requested Purpose for which Record is Required: What is your relationship to person whose record is required? ~ <5tJG' (} I S-eav) C-e-. S ' Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Middle Shah Maiden Last Local Registration No.: (If known) Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, you must submit documentation 0 I right or claim. Date Signed: FO RE Signature of Applicant: Month Da Year (P 2012 Type of 10: o Driver Lice se Issuing state: ,. Timothy P. Do Ie (Applicant's Name) 371 Hooker Ave. (Street) Number: o Other 10, Specify Number: Poughkeepsie (City) NY (State) 12603 (Zip) Type: Number: Telephone No.: )(845) 452-0460 Type: DOH-294A (06/2005) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coey of Marria"e Record Search and 0 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. ae.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 CerIlfied Transcript may be needed where proof of ps'8/'11Bge and certain other de1ai1ed information may be reqWed such as: passports. veteran.. benefits, court proceediIlgB, or seIIIement of an estate. z~::~,'i;ji,:~~':':.,:>:,' .~', " N~" .... ~ '. 0 ~ '.. .;~o:;<:f-:~>:.:~>\>. '<:a~L..:'.~' (Last) J Name :ride Joel I Bride.. Age I Co :r.,Dateot 10 - ZCf -h h Residence :ride Oaf0hes.s If Bride Previously Married, State Name Uaed at That Time Place Where Marriage W. Performed (Fnt) (Middle) (Last) rn Pod rstJ (Slate) (County) ~(yte) For what purpose is information required? _fYi -5S ~. What is your relationship to person whose record is requested? If 88If, elate "88If.- SeJ. f In what capacity are you acting? If attorney: Name sncI relationship of your client to persons whose maniage record is required. ,;:>:: z',;~~.': ',;'t;.. '~'. ~. . ':', . ;' Co :'...:",: . ':,;:'J .~.z.'.'.>;>~:'i!~ Sj;iof7h~ (1CWh' Address of Applicant Ie Dawn lar1e P lefjJdfL+ Ua1illj AYI ) Z~b q Dale s-- ZS"-' 2tJl Z Please print name and address where record is to be sent DOH-S01 (3/85) (PLEASE SEE REVERSE SIDE) OJ",. i , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coey of Death Record . . ..<:PL.$ASI;.COMPI..StSFORMANOENClOSEFEE....' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. >.. . ...... < ., UHF ,...,-'...:....".,. '.... Name of Deceased Date of Death or Period to be Covered by Search :J~ VJ. ~~ y - ) Cl - ")/0\ L First Middle Last Name of Father of Deceased Social Security Number of Deceased ~~ b~ IbLt-~2--\4~Y First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~ ~ CA\~ Lt -~- 2,0\ -=1J- First Middle Last Month Day Year Place of Death , ~\OB ~d-~~ 0\~1 ~ W~f?\~\8 GIL~ V vd-t:\I1cSs Name of Hospital or Street Address IVIII~, Town or CI County Purpose for Which Record is Required ~u~ llQ O--~'K ~ What was your relationship to the deceased? ~~ ctLv~ In what capacity are you acting? ~~ ~~~ If attorney, name and relationship of ~our client to d3ceased - Straub, Ca alano & Ha vey Funeral Horne ~~,'~-\~ Signature of Applicant ::!I~'lrC'(~: Address of Applicant u .- EO. Box I~I . . .lOp .. . .. G90 -- ....,'......cOMPLETEFOR OEATH~:fbccU'RRlNGASOFJANU .... . Number of copies requested with confidential cause of death - ~ ~ Number of copies requested without confidential cause of death PL.EASEflR.NtNAMe.'ANoAOQFt~$$WHSA!$R$t::ORO$HQOL;b.Ele.$eNT':':\i. .....-..-........ .... ... ...".......... ,......... ... ......................-...., ...',..'................. . Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Cae)' of Death Record ...... ..... ......PL$ASI;CONlPPETE<PORMANOE;NCLOSIEFEE<>/... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ._~ c:::t. First Middle Name of Father of Deceased ~-T First Middle Maiden Name of Mother of Deceased ::kl0\ k~ First Middle Last Place of Death N~:i~o~1 ~ ~ \7i;\\=:. Purpose for Which Record is Required nl~ Last Date of Death or Period to be Covered by Search L-\- -llD - 12- q'ne~h Last Social Security Number of Deceased Ow - ZZ-Si<2c:> Date of Birth of Deceased 3-\S- \9~9 Da Year Age at Death 8~ Month ~\~ ~ Count ~C'-F~ A.~\~ What was your relationship to the deceased? -~VV'"~ \ .t::?~dl;- In what capacity are'- 0 ting? t"'""::\f\ ~ m \-P ~ ~ VV\~ If attorney. name and relatio hip of your client to deceased - \1-\2- Signature of Applicant I',: Address of Applicant f" .. . ..........,."...... '.<'cOMPLETEFOR DEATHSOeCORRlNGASOFJANUAff. N mber of copies requested with confidential cause of death fR1~CC~~W~[o) _ Number of copies requested without confidential cause of death ......................tj..PL.EA$E..PRtNTNAMe:ANp.APDRE$$.:WtiSRERSeORO$ . Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local.Regh;trar for COe>' of Death Record . . . . . . . . . -. .... ".. ::;:::;:;:::;:::::::::::;:::::;:::::.;. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased . M~'( First Middle Name of Father of Deceased SDW.st"AG Last .:;..A. . ;i:P. ..: /Q'RJrtpEit:ti\tt:i:ttttitff\\ti}@ttti:i\:::tttttttttti\:i:i:i:i:i:::tti:)lt:i:i::i Date otDeath or Period to be Covered by Search It 21../~1' Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased o 1> '30 Month Da lq3~ Year Age at Death 72- First Middle Last Place of,peath \ ~ (:)A\l \ rt"S \)~ Name of Hos ital or Street Address Purpose for Which Record is Required ~~G.d- N't' l2SCtO Villa e, Town or Ci oor~s Co un N~"\)~ DIZA~~ '~'JU\lGPrLLOtJ What was your relationship to the deceased? N In what capacity are you acting? ~\...\ c.,f(:.. Of"Ml' Y ~ If attorney, name and relationship 0 youli client deceased Signature of Applicant IN . .{ DaleOltbJ-d ZDI "L Address of Applicant ,S?, M'D[)L~'S.b P::D'I""AfP.(J~6~ -.,...:)'( . tZsc\'O fffilf!Wi!@ffitlfffifiMtli:i}f}:{.::.;;;..:....;;;,.,.::"'f"':: . .. y"':.:":' .<.::....t ':": "f.":.. ..:..:. ..... 'f ..". .',!.' '..: ." .... .... 'l'.:!......:r':'::):r-:,:<.:.:."....r:..:..:'.~.::.:;.;:t..~t .,.:.....:.:...'&ftm@~i~ifr@~::tM:f}t!ttiltlf!@!@!ltt:::tii:i!:!::i Number of copies requested with confidential cause of death - Number of copies requested without ccmfldential 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 Reg istrar for Col!)' of Death Record .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :~*=~?:~fft~l~~~~j~~~ilim~ijm~~rr~~;i~@rt:~~rnr~~l~~l~~ilil~~~tttmtrjt~it~@rjittt;m~:~rr~r~rf~ Name of D?ceased (j) ILL //1-/1{.. m /t-R.-fllJ First Middle Name of Father of Deceased #bKliAfi-M First Middle Maiden Name of Mother of Deceased QIThz/f! ~ ~ /tJ/fRtVe r' First Middle Last Place of Death c2.tf- 8 S (! IT R IJ o/"o U <) 11 wff/J/J. fir LL s . ;tI'i Name of Has itaI or Street Address Villa ,Town or Oi Purpose for Which Record is Required I-flJ S u. e..(t IV C IF ?o 1/ <!. Y . I? D'tAbhI/J Last Date of Death or Period to be Covered by Search :2 .;). 7 - /(i)... t-o'f/J!> Ie / ItJ Last Social Security Number of Deceased /6 tl- 30-/)(0 q Date of Birth of Deceased / q Month Da LIP S? Year Age at Death 75 What was your relationship to the deceased? Lt ve 7/v (! ~ I'Yl jJ /I- hJ J t:J tU In what capacity are you acting? S e f-F' If attorney, name and relationship of your client to deceased Signature of Applicant ~~ y ~ Address of Applicant Ci{ef' B S!2/feho /'011 c; A L-;:J- Date c.j-:2. - )2- u). F N Lj J2-SCf 0 Name Address City State Zip Code I I I I I I I ! i 1 I I I I i I I i '~i@fMmtWmr~!r~r1ir@mm~~~tt!t1~t~ttf~~~~~mr :.:~.: .....:v.~ .... .~~.. "::": "'l ....: ....... .:~:......... ....... ...........f. " ':.. .. 0".. .. ....,. .. .:" .~. J. ," .J(:....~ .:.........(..: ...........l~;. .~:~t......... Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death ~~(C;~~~~[Q) APR 0 2 2Q~2 DOH-294A (6/2000) ff . " NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record . ..... ........pteAsecOMPCETEFORMANDENCLOSEFEE/:............... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Nam? o~ Deceased MCl \t:.c il'\'\ First Middle Name of Father of Deceased 1f'\c'l'\'\C6 ~'\]ct~Y") First Middle Last Maiden Name of Mother of Deceased J L-, \l;\ --,-~V\O Firsf,-J Middle Last Month Place of Death 111 S ~.5te\ 'A~ Name of Has ital or Street Address Purpose for Which Record is Required E=-V\C\ o-t' L-t-h ~\~ V\J~1~" .Date of Death or Period to be Covered by Search Last 3-.:30 - 12 Social Security Number of Deceased \ ~2 - 3<0' -=7 '::f 2. '-I Date of Birth of Deceased \ -z - \\ -. ?:>-=1 Da Year Age at Death -=f'-\ nnr~.:F~ Count What was your relationship to the deceased? _MA V\.{ V1A. \ '"L)i If'e.rtzh.. In what capacoy are ~ou acting? CV\ ~ Ired ~ A f'fhVV\ I ~ If attorney, name . nship of your client to deceased ............ COMPl.;.ETEFOR DEATHSOCCURRINASOF.jANU....1:)198S/: ~umber of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death .,,,....-.............. .............. ,..... . . . .....' - . . . . . .. .. .... . Signature of Applicant 'f Address of Applicant 1\; !, ............)\......pCi$A$e:PRINT)NAMe:AwoAoDFtes$..WHSRI$.REC()Rp.$HOU~b.$e..SENT ............. ....,...., .... ........., .. .,.,.. .....-......,...... ....-..-... ..-.... . .....,............-..- ........'........'............... ..............-,........'.......'.,..........'......,..',:-.... .....-....,.........,..-.'....-. ..... ..... ..................... .. . .. ....... ...... Name Address City State Zip Code DOH-294A (6/2000) d8 NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 I Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-lO: -OR- B. Two (2) of the following showing the applicant's name . Driver license and address: . Non-driver photo-ID card · Utility or telephone bills . Passport · Letter from a government agency dated within the . U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Cengiz First Middle Date of Death or Period to be Covered by Search: (mmldd/yyyy) Ceng 056-54-2541 Last Date of Birth of Deceased: Age at Death: 04/0412012 From To Maiden Name of Mother of Deceased: 12/06/1962 49 mm/dd/ Death Certificate No.: (If known) Sabiha First Name of Father of Deceased: Nizanettin First Place of Death: 5 Harbor Hill Road Wappinger Dutchess Name of Hospital or Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death 6 confidential cause of death copies requested 6 Purpose for which Record is Required: What is your relationship to person whose record is required? Middle Tinur Maiden Last Local Registratio n No.: (If known) Middle Ceng Last In what capacity are you acting? Funeral Director If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, ou must submit documentation of a lawful rI ht or claim. Date Signed: Month Da 04 12524 (Zip) ,. Address of Applicant: Anthony J. Calabrese (Applicant's Name) 1028 Main Street (Street) Fishkill (City) NY (State) Telephone No.: )(845) 896-6166 DOH-294A (06/2005) t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Col!.}' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. . . ~i~~~~r~~~i~i:~~~~if:i~j;ifr~i~~~1~rjft~~~t~~~~1~f~~~:r~~ii~i~~@r1~1~l~i~~~:jjj1~fjlfr~~rtf~;jtl~@i;~~~!1~im~~~;[~j~~1~;~m*1~~~~~~j~~ :JT:Y:t:::, .T'T 'I.... ~~: -'..-:"': j***j~~j~;;~~tIm~~!~~riifl~j~~;m~~f:~ii~1~1iW~~~it~1~~~~@j~~j~i~ji~i;~~tij~~~~jjj~@jj~HrJirj@;m~f{rrr~~:~irt?tf~~~ Namtff~~ed L First Middle N8f"e of Father of Deceased Ice" First Middle Maiden ~ame of. Mother of Deceased SQ t\ d First Middle Last Month Place of Death r .II. I"" to a I '\I (Y\1l...'j P' \,JJ J' 'f<r . ~ r--- Ulr'QcO' b'1 Date of Death or Period to be Covered by Search Last H ,\ r'Y\~V' Last Ifl)~ Social Security Number of Deceased Date of Birth of Deceased Age at Death Oa Year Name of Has ita! or Street Address Purpose for Which Record is Required Ih~u...vG What was your relationship to the deceased? In what capacity are you acting? n attomey, l181li0 and ~ your client '" _ad SignatunlolApplicanl J? ~ 14 Address of Applicant & Ci I I) (Y\9..yr ~ il"-t-- If?). ~'fj3~ Wopp r-) D<: i /2SC10 Number of copies requested with confidential cause of death . _ Number of copies requested without confidential cause of death . : ::~~i~~m~~~f;~;~~~~;;~~~~;t~i~m~~ ~t ~ ~~ m t~t~ 1~r ~~ ~ ~ ~ ~ ~ ~ ~ ~[~ ~ ~~!~ Name Address City State Zip Code DOH-294A (6/2000) ; NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Loca' Registrar for COE!)f of Death Record FEE: $10.00 per copy or No Record Certification. Pleaae do not send cash or stamps. . . '.PNN'rOR TYPJi Name of Deceased Oat. of Death or Period to be Covered by Search Kenneth H. Quandt April 13, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Herman Quandt 112-26-1156 First Middte Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Harriet McKee January 25, 1937 75 First Middle Last Month Day Year Place of Death 76 Helen Drive Wappinger Dutchess Name of Hospital or Street Address Villaae. Town or City County Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home of Fishkill, Inc. lf attorney. name and relationship of your client to deceased SignoIur8 aI Applicant ~ J'-.S<, Date April 17, 2012 Address of Applicant 1089 Main Street Fish kill NY Name Address City . . " Y ... '" . ;: \ -1!L Number of copies requested with confidentiat cause of death _ Number of copies requested without confidential cause of death State DOH-294A (8/2000) ?- '.=.',V YORK SiATE DEPARTMENT OF HEALTH . 'tal RecordS Section . Iff) Application to Local Registrar for Copy of Death Recor9 PLEASE COMPLETE FORM AND ENCLOSE FEE (jqo - !/.p - 35'85 .i ~ 0 :II " ~ '" ~ .. ~ ~ E '" ~ ~ .' . , .. , i > i c: . 1 g ! ;:EE 51000 per copy or No Record Cenlficatlon, Please do not send cash or stamps. ',ame of Deceased Mllrl1 X re.n e.. Fl1"st Middle ! r-.Jame of Father ot Deceased . M Fch Cl.eJ 5 +e-f1an[ k First MIddle Last ',1Clcen ',\iame or ~'lorr.er of Deceased M Qf:\ Ze.le.z.ni k First Middle Last Hflrras PLEASE PRINT OR TYPE Date of Death or Period to be Covered by Search J..fJ/7/aO/~ Last Social Security Number of Deceased ::':!ce of Death 1 '3 L./LJ Date of Sinh of Deceased I~ Q Iq~(9.. Month Day 'Year Age at Death Roufe... o7~ FaJ 15 ~9 i \ Du+che.S5 i , '.ame ct HOSPital or S:reet AdOress ;: -r;Jose lor v\'hlcn Record IS Required Coun on be.-hoJ-P 0 -f' ~Qff); ~ :. ~at was your rela!lOnshlp to the deceased? -Pllnern..) d, 're..c.. rOr :- .,,'nat capaClry are you acting? IA . ::;1orney name and relalJOnshlp of your client to deceased ,,,;nato'. of App"canl ~ "N ' . ~ ".Oat. 1/7//7 ':':cr~SS:)fAppllcant.3q 5t>. Hflmi/t-f)r) .3+. POtJfl~"d,'''S>~ .-/'1 5i'e N ta~OJ .,~ / ....:r~ ,~ COMPLETE FOR DEATHS OCCURRING AS OF JANUARY 1 , '''Zip Code .. '......~m::ler of copies requested with confidential cause of death - Numoer of copies requested without confidential cause of death PLEASE PRINT NAME AND ADDRESS ',c.'ne "':'ccress -- . ~~l State ::~.29"A ,6i981 &. . '"'"Inll ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record . ::i. . . :;:'.: . :~j_:;ttftitjtt:t~::;:t;@)if::jtfjtttt~jj:t:"';:(j)jj\:::::, f I !. i I FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased )v' RiteR- First Middle Name of Father of Deceased /YtJ,PR First Middle Last M?):;;-~OJ/V;; Deceastt #/;f(l/J/# First Middle Last Place of Death ~/ /)J p..)g,eJ C(jIfA/~S ~r/. NEmle of Hos ~ or Street Address Purpose for Which Record is Required ~ TJ"t :'1': :V~'T :.... ~...: _...-:'<-; :~~;;~~;f~~~?:~f:)~fi~@i!if:mrmf~~@~~l~i~mlitii~r~~i~iiim!i~ij@i~j~iij~~!iiti1i~1~Hir!1t~i@i~!{ft~~#ii~i!i~j~fi~irrt~~ riff!t~ir~)~iiffi!f~!f@ffj~r1t~tf~~i!~r!i~~~i~~~l~~~!t!Jti~@fi!;it;iii;~i!~!i~@j;ff~1i!m~~1~~~~~!~~i~~i~~ii~~f:~iii1ti J/Illld Last Date of Death or Period to be Covered by Search 4/tflt. cP~ /J()/~ Social Security Number of Deceased 07/ c:lf J7d05 D;i of Birth of died J!c1& Month D Year Age at Death ?/ ~/)7l)lt(; a/Mer Coun What was your ationship t the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased s~n~~mAP~~1f'~ Address of Applies . . $p:'~'~J~ ~ . / (;1? :frrr:r!~ii~I~!!;i~~:i~tfi;t~M1~~1tr~1!;1~~~;~11~!~~1t~lr: ')': '.' ...., .......f "':: "';'" '::":.:~" ,',' ...~.. ..... ....~.. .:........ ........ w ~.., '. '.' .... .. . .... .~ '.' ::'.' ..J':' ';'.' ..:..... '.' .,;., ..:..-...-....~ ~~...';:1~~r...... ..w.......~~1W~~l~~~~1~~t~tmrflmtm:rt!~~!j~~~~i@m!;~if~ri~i~f~f~j)ij* \ Number of copies requested with confidential cause of death -I:L Number of copies requested without confidential cause of death . : ::~j~~[~~~~;~;~~1~1~m~[~r~~;1~~;t~~~fH~@~~m~mt~~~~~ff? Name Address City State Zip Code DOH-294A (6/2000) g '(j~f/ ( )- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.}' of Death Record ... .... ... .... ....... .....PLliEA.Si:COMPCETEFORM.ANDE;NCLOSEFEE.. ..... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased -::::b"hV"'\ -p First Middle Name of Father of Deceased ~.f~ First Middle Maiden Name of Mother of Deceased ~a.rq"'re..-t ~~ FirsU Middle Last ~~mCi\e. Las t -...J .Date of Death or Period to be Covered by Search "-'a.rch 7-2-, ~\2- Social Security Number of Deceased J...-tL-Ep.m ::1k Last \2=i - 28 - ~'-\sa Date of Birth of Deceased 'i - ec>- 1~39 Month Da Year Age at Death Place of Death 25 D; l'vtarco l=1a.~ Name of Has ital or Street Address Purpose for Which Record is Required ~~\~ T2- blA;e~ Count ~ ~-tJ L;~ A-\-b\~ What was your relatl~nshiP 10 the deceased? ~m, ~ ~ In what capacity are you acting? CV\ . 00 If attorney, name and relati nship of your client to deceased . Signature of Applicant Address of Applicant . . ..1....19 ...... . . ... :).. ;>> : .88.:<...::............. Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death ... .............;:..:..<...;...pJ;.;i:ASE!PfUN't.NAMEANOAOORt$$$.WHERt$RSOORP$H<:>OWbae'SeNT') . . . . . . . . . . , . . . . . - . . . . . . - . . . - . . , . . ..... ....... .........-....-......... ....., .......................,....... ..... ...-..............." .... ...... .....-....... . ... .. ...-.........."... Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Appli-cation to Local.Registrar for COe>' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :::i'i:i:?ir:i:tir:i:'t:tti:it:::':i:tir~:trtirfrtttirrtt:i:it:i:tfmttttrtit'i:i:tiii::rr('fe ::: ;...... : r ;.;. ..: :t.." :8,::, ::i';, ;." Name of Deceased Date of Death or Period to be Covered by Search ::r~~ V,,,A\.A'":) , First Mlddle Last Name of Father of Deceased oa\\'-'a.o\~ 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 Place of .Death ,At;) S""f''--I. \:)~l~ Name of Hos ital or Street Address Purpose for Which Record is Required p ~'c:.'C \ ~\J 'i. ':aT\ L..""...~ Month Da Year ~~~, M\.\Wt.. , ~..\ ViUa e, Town or Ci ~.O'''s.s Coun What was your relationship to the deceased? ""'~ In what capacity are you acting? ~C)""c.'" \~~,.c..'" c..~~~ If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant .~~ "-II~ .A'11)~ ~ Date 05\0$\\'). \8t-\..~~'-'i" ~\.A""" ~'. ~~f'~l,,_""(\.\ ~""""~ N"( \9.'!tQa ~. Number of copies requested with confidential cause of death ~ Number of copies requested without c~nfidential cause of death lttlittfIfttl{tftmtitfMtC::.'i..;.....,,>:.,..;..,.':::.....: .;....;f..:.::... "~":"'::i' .... ..'i....:., .:;~..~. .... ':;:' .:.:.;. .' ~..,~' ." ......st .':.....l7:...::i;r~::...i'.<....~..:?"::. "'.. . ;r'{r:""':';':':""\iimiinrlfiItflt@iit:mtlitff~~r;!rt@iit,::mt Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DP:PARTMENT OF HEAL.TH VITAL. RECORDS SECTION Appllcatiorr: to LOCal i';:.egistr:aI' for Copy of Deatl.'i Record \ t' "'!.4 ~. ''''-.....0' ................. ",,'1.- r _ . .- -..... _M'~~-"""'f"".r~ Jldio.....::!.. ~"._""""\l:".~I'~"'~~Il'I"!:I'" . II. ....'..::;/:~ Fe~;' .rt.ionC'08 Cou:nt~ . $30.00 J O.t(ler ~fstrict5 . $10.O;Q pel" c~rtfffedl copy or No Record' CertlflcatEo.t'l! "<c.;., ldientU'fcatlaof1 Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made frQm a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-tO:' -OR.. B. Two (2) of the following showing the applicant's name . Driver license and address: . Non-drlv.er photo-ID card . Utility or telephone bills . Passport.' . Letter from a government agency dated within the . EmploymentlD " last six (6) months Name of Deceased: Social Security No, of Deceased: 6.~( CIlKo. ~ Wk.\t) tJ~2~ () 51- 5:;)- /07:2 Date of Death or Petiod to be Covered by Search: (mmId~yyy) Date of Birth of Deceased: Age at Death: Ft!~20, t2~o l d- . t Ql/Zi~ {~7 Mald~ r~ :C~ Deceased: . tJ t; I- ~ ~ ( j Deelh ce~r"'"te No. (If ""wn) First . Middle Meiden Lest Name of Father of Deceased: Looal Registration No.: (If known) ~nj"-P1~ _' W~;-k P,acer-bl../;;2::.0o Hcr>--L. Wet..~ ~((S 9u~,s, Number of Copies Requested: (For deaths .occu"ing liS of January 1, 1988 spsclfy with or w/ihout confidential cause of death.) '\ Copies requested with Copies recjuest~d without Total number of <!' confidential cause of death confidential cause of death copies requested '- ~ Purpose for which Record Is Requ red: hat Is your relatonshlp to person whose rec~rd Is required? f attorney. give name and relationship of your client to person whose record is required: :.; .',.' .:: ..>~.;;. ~.f yo'~ lii:'.' riot the paren or Child ~f' e deee~ed or the ,pouse of the ~e.eea~Ct ..... . ... :'. .;i.~:>,..::: ;.;..::;<': :,....t:~"':.. t'm'@! ,qf. deBthl )'QU a:nus$: subridt documen~tion .o,f a {aWful r(ght.. i:jr c.laJm, .. .:' '.. ."; '" ;. . . . Date 1,...&. " . .. ..... ~..........."........ oJ. a:~Ii't':'-"" ,..11 ~'i;l.'t: ' ~'t::'l(';i"~' -;'i1,'\'.ql'" ~ .....-. .I:.....:i..:~.::...:~ I.bit:h:'~ ~ 'DifaQ ~q; ;:{!:i~;(~~;':l~i.X.::-~I:f:.~ Signature of Applicant: Mllnth . ........ 'Pli.,;..' .~~.~~"~"., '::,];.1;:.'J.""l;'J:Il!I '. "'~..i,P''''I'' ..; i.'::',i";!";~ t;+< ." .; '(rlll'lI'bi:lGP.YILl8i\!ialU!~"'~'I:I.F,';u" 1~1J... '~J.' ;:.!.,,,,1"':.:~" T' ~ flO' ........ ......' \....~~ .. ..\" ,.;. ...'. ..:.,...... Q.D~~i~iDin~e: .::., . ':'.;" ~:!,,\,. ;': :i.:':\..:~:;;:::.':!i;:;:; ::'!;,:;+::,::)';~.:;'..::<:;\ Y . ,,:'i i '.::.:.'.:,: ::.~ ...~,~. '.': ':. .:. I':;':" :; :.>.?:;:'~::,:.;;:.,;.::~.;~>:;.r\,:,:,::,':;'\..:'/>: \\;'; J~lh1i '\iilEi. '. ..'''" ....; .:....i ,,,', ."" : ..j...fl..."."."i....h .......if.'...'.'I..........;~';\'; . ;. . i.'.. ;' .'. ~.. ." ....: :,:; . 'f,:-:~ . :.::::::.:::?~.~:../::}.:~:.;::;.;'}!;::~!./\::,~..;l.;;;:~}j taxllllll~i1j)n d~te . '. .. ..... ..'''. ...., '. .. :.' .... ,'........."': '".. '1"""'" ,. . .~~t#' '.. ,;..,.... .. ;.. ~:;, j:.;, ..~:r:,:':'!:;;.2;;):;,;;,~:;:;';f,i: Opther.1p. ~~~c,fy . .,' '" '.,: '. '... ;~(;;';.;:> , . , ..: . ~ ' N~.~~~r: . Address 0 pI/cant: I \ 1 J Je<'vvtW( L.. VVq ( t1A II (Appfic:snl's Nwme) '/ ()7:S (~~bvr ~ 11 (S/reet) ".. . . Vo (\WJ~ / N 7 !070( (Qil),r '\ I (S/Bte) (ZIp) Telephone No.: f ! C() q ~ 5 --:3 7~ ( . ~ '. .t Type: . '. ,";'<".'!.. Num!>~r:' Ty'p~:' ,',':1".\' ,I,: ;~': . DOH.294A (Q6/2005) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ',:,:":, ,':::pCI;ASeCOMF'l.ETEFORM AND ENOL.;O$E FEE .. . . ,.:,.,". FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ," "." ........-...............:.....'..;.:..:....:::<.:.... .....,.. """". ..,..... .".. ....... ........ ):<:P'USASE':PRINT'OR'TYPEi\::.:::'.,:,:,"': .. . . Date of Death or Period to be Covered by Search t=e.lo.~. ~\ 2.. . .-.--."..>.-:-....'.;.'.......:;.<,.:..:.:.,.. . .. ................. Name of Deceased q~dl.O Farst o....J Middle Name of Father of Deceased ~ho First Middle Maiden Name of Mother of Deceased ~c-n Cl'- N;e.."~~ First Middle Last -rc;-rre~ Last ~o~o Last Social Security Number of Deceased "1- - Z-'1 - O<D~ Date of Birth of Deceased t'-b\J. Z8 \ ,q7..6 Da Year Age at Death Month 8<0 Place of Death Zo ~fV\O"""",,'~ Name of Hos ital or Street Address Purpose for Which Record is Required Wo-rrl ~e.r ~ Count -r:=:-~ 0-+' L;G.- I\~,.~ What was your relationship to the deceased? ~~ fZ'L l n ~1?IL. In what capacity are you acting? CV\ ~ LeE err .Q. ~ If attorney, name and rela nship of your client to deceased Ii I !D Number of copies requested with confidential cause of deat Signature of Applicant Address of Applicant rRi~CC~~W~[D) _ Number of copies requested without confidential cause of d ath RL;:~A$EPRIN:t.NAMe::4NtjAPORe$s.wH. . Name Address City State Zip Code ~ nOH-?94A (6/2000\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record ..... .... .. ... ...... ./<etE.A$I:OQMPWf;wJ:iIH;;?:J;U0:'ANPl=NQt;;Q$SFl;$) ... ......... ..... ... ... '" .............,'............ ..............."...-.... ...................,....... ..........,..'................................ ..... ....... .... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased V~NDt:I L. First Middle Name of Father of Deceased R;:J L PI-! First Middle Maiden Name of Mother of Deceased .J UL/ A L lJ<!llc. UCL.. I First Middle Last Place of Death II FteI9NJ./LINZJ4'L€ ~I/l: /VeNN J Last Date of Death or Period to be Covered by Search /L-?/7'73o, /912- Social Security Number of Deceased /IIl:/II III ) Last 09&.1-/6 - 23'1-9 Date of Birth of Deceased //fJR. 2~. Month Da Age at Death /913 Year ~<J tv fitof1JI/\f6 E:Rs Ft:; LL5 .P UTc.1j E.>S Count Name of Has ital or Street Address Purpose for Which Record is Required 10 eoJ.. LEe.. T I 1\1 ~ ulZI1I1/C€ Signature of Applicant Address of Applicant ~ ..".....'...........""............................................. ._......,-...', ,.......,...'...---...........................--.............. ::':':::>>:,"<<:...>n'..>)}):)$QMp. ) ~ Number of copies requested with confidential cause of death - Number of copies requested without confidential cause of death )Pt;;l;I..\$EfUnN1rNAmEANP::;'Ot.l8S$S'Wliunn;:!I$Q<.t$O$HQU4P$e$$.Nlt:<< Name Address City State Zip Code UJ aLL -....ir-;/ DOH-294A (6/2000) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar tor eoI!)' ot Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. p: . E"PRINT'OR TYPE Date of Death or Period to be Covered by Search March 19,2012 Name of Deceased Louis A. First Middle Name of Father of Deceased Angelo First Middle Maiden Name of Mother of Deceased Anna First Middle Place of Death 59 Brothel5Road Name of Hos ital or Street Address Purpose for Which Record is Required Lucato, Sr. Last Lucato Last Social Security Number of Deceased 134-26-6736 Centorani Last Date 01 Birth 01 Deceased May 25, 1935 Month Da Year Age at Death 76 Wappinger Villa e. Town or Ci Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. " aHo,ney, name and relation hip of YO\l' client to ~ Signature of Applicant "- Address of Applicant Hopewell Junction Date March 20,2012 NY .... "':':"'~f:' "1,:1.:,:" -1.Q.... Number of copies requested with confidential cause 01 death _ Number of copies requested without confidential cause of death Name Address City MAR. 2" z: :2 TOWN OF WAPPIN TOWN CL~R~ DOH-294A (6/2000) g NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Col!)' of Death Record t:(:::tttIt:~:f::ffm/t/:::f~t:::::t:titffffflrr:::::':,:t::::,::tmp ::: .. ..': . . . .. . .....:: .:. :~t~1~11~f:~~~~i~~tJ1~~-;~i~iM~~j~ij1~1~~m~~i~~;~;~t~~;;~~~~~~t~ftt~~mrrmmr~~tt1rtr:r~~~J;~~~ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :t~:t~~#{~~1~~j~~~~jft~~~I~1~~~~*~jj~~~m~m~~tl~~~i~i~ili~~~i;i;~~~m~jj~j;~ii~1i11ii~;!~~it~;~tt~it~i~f1ft~~~1~1~~~~~1~m~m~~~r~~~~~ . . .. Ro~.frm,& Last Date of Death or Period to be Covered by Search Pnbttbl"f Au~~ g.IJ1~g (bl.tf- lod< bhJ a 0 <a l l' (,~ ~ ~ P,) ICfr.-C(. Social Security Number of Deceased Name of Deceased 4vWcUU First Middle Name of Father of Deceased J~ First Middle Maiden Name of Mother of Deceased Jv.kiv First Place of Death g (Ve rt.-rt s f- P.. #~ I- ~~ Name of Hos ital or Street Address Purpose for Which Record is Required !Zo c,Afw~ Last Middle Date of Birth of Deceased Age at Death Month Da Year IT ~1'f'+ Coun What was your relationship to the deceased? ~ rt.t-r.L~h<w In what capacity are you acting?a~ .ev.W/J'r ~h.U c80oro\'h.j 'R~ ~ J If attorney, name and relationship of your client to deceased ~ tkhfwis niece. Signature of Applicant ~ '4/ ~ Address of Applicant Date M~w.Au f&,. UJ' 2- _ Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death Name ~ud~;l L,P! Address Po /30 'y 7017 t.j City Ph,'CA..~ ..'1, .' ,.'.., .:::.. .: ::'..U ',:, :.) It: .., Ietvu- pvd- ~ ~ Au.mk;v (,iVl 'd~ ,4-B1t- 23 S- 6- V State ---..M Zip Code 19 , 7' DOH-294A (6/2000) !fr Trent Duffy 31 Jane Street, #17 A New York, NY 10014 212-807-9204 (home) or 917-280-2440 (cell) tcd31@netzero.com March 6, 2012 Clerk's Office Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Ladies and Gentlemen Re: Adelaide Rochford, died August 1968 Enclosed is a request for a copy of the death record for my great-aunt, Adelaide Rochford, who died at the Rivercrest Rest Home in the Town of Wappinger in the first half of August 1968. I have filled out the form as best as I can, but there is no one living who remembers Adelaide's birthdate or her Social Security number. I have a copy of her obituary, but no age is listed-I guess in those days it was considered impolite to print a woman's age in the newspaper. When you find the death certificate, it is very important that you mail to Prudential Life Insurance at the address noted on the form with the following information: Reference claim ABR235GV. That way it will be put in the file for my deceased aunt, Dorothy R. Duffy as proof that the beneficiary of the policy (Adelaide Rochford) predeceased her. If you have any questions, let me know. Payment is enclosed. Sincerely yours, /~~. Trent Duffy Executor, Estate of Dorothy R. Duffy encl. 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 of Deceased ~ [)"\01.fL W. kl CL P ro-th First Middle Last Name oj Father of Deceased _ \ l L....J.- '\..) W LW Q.i'Y1 ~ r (J'I1\ (.,{. LV-l:) First Middle Maiden Name of Mother of Deceased Date of Death or Period to be Covered by Search :Jttn 6. ~ 008 Last Social Security Number of Deceased ~f\- First Middle PI" of Death (\. ...p Lf POJd::.. MVL.J1U ~I Date of Birth of Deceased 10 IIOjlClLio Month Da W~P'J flge(5 ~I I'J Y Name of Hos ital or Street Address Villa e, Town or C' Purpose for Which Record is Required TI+Le.. I ~L.LL, \=bre-~ Pro{J-e e" Age at Death Last Year toi- 1~5qO Coun F1oitcL.tL What was your relationship to the dece~ed? ~'(\Jl.,. ... ~ In what capacity are you acting? M MJI S e~_ :l-1 +LL A-ff (11 ~ ~-l D +- \ 8--A If attorney, name and relationship of your client to deceased -i1..A C~ Signature of Applicant ~ ~ M )-110J-J,. ~ (0 ~I ~ AddressofAPPlicant~~ L/>>L#JJ1 1=L 33~'=>d- I _ Number of copies requested with confidential cause of death j 1P"~of copies requested without confidential cause of d~th ~1~ftfj~~iin/~~it~f1~~~~Jtt~~~~~;~~;~mmmtt~~~r :.;: ::: .... :~~ .:.:11 . :. .:;11: : : .' ,,' :~~ ,;.:. ",: ":=;: ,:jiIlIK: ': =:..D~~~~C~~ ~~cr~~L City G..JPSJ.- P~'Nl fuD Lh State PL- Zip Code3340Q DOH-2Q<A (6~ FLORIDA DEPARTMENT OF INSURANCE ..CATHVRltEM HluBIXRF ~iLic;;'2S5 IIJ 6876 >18 lICEtt8.ED TO TRANSACT. THE ,ifQu.OWING CLASSES UF INSURANCE: ;/Tftle NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record PLEASEC:OMPl....ETEFORMAND ENCLoSE FEE > <...... ..... .' ". FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~\ u)\'fY\ WclSor-- First Middle Last Name of Father of Deceased ~ W~ ..Date of Death or Period to be Covered by Search ~ '?D j/Wl2- Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased \..A \ Firs;) Place of Death y~ <3., ~.s.\..eJ\.., ~YILLL Name of Has ital or Street Address Purpose for Which Record is Required ~ ~ \i.Q O--~lrs Last \ ~ - 36- ~.-:t~ ~ Middle Last Date of Birth of Deceased \~-\l- 1t1?>~ Month Da Year Age at Death ~ ~~) Count What was your relationship to the deceased? ~~ ((e~ In what capacity are you acting? 'fSY\- ~-R ~. ~l..c.-t , - If attorney, name and relationship of your client to deceased Straub, Catalano & Halvey Funeral Horne Signature of Applicant i:; Address of Applicant GS Ensr :\.ldin 'slrcet I~u. HI),X J J I Vv'appmgers Falls. N. Y. 12590 Date 4'}'lr 1':, Name Address City State <COMPtETEFOR DEATHSOCCURRN . ASOFJANU .' ~ Number of copies requested with confidential cause of death ~ Number of copies requested without confidential cause of death PLEAsE Pfl.N"t NAMe: AJ'.AP APDRf;$$WHSR!$'flSCO.Rt)'$ ~4A (6/2000) J~ I l , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for ColD' of Death Record .....H.... ..:Ptl:SA.sr; COMPLE'tEFORMANOENCI.,.OSf; .PEE>>i. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ..' .........::d. .. .....:.:..........:>>.pteASE.PRiNTORTYPt:s:...:.:i.. ..... ..:..<:::...::..... Name 01 Deceased f YY\ (\ ~. k Date of Death or Period to be Covered by Search -;J:~Y) Middle Last d '3' ;rd-. ,- ~, L Name of Fa~her of Deceased 11 _" _ _' Social Security Number of Deceased -r~1v\a.. me tl/ify l~\.e \ d-~ -J-<6-L{ L{ ~ First Middle Last U Maiden Name of Mother of Deceased Date of Birth of Deceased rY'\tA~V--.e\c- ~ 4 - ~o - \~~; 't First - U- - Middle Last Month Dav Year Place of Death ' t:"":.. .1.... a-S- D'\~e.o 'P~~ W~t>\~ ~ Name of Hospital or Street Address rvilra~, Town or City Purpose for Which Record is Required ~~ \\~ ~~ Age at Death :t-~ ~~SJ County What was your relationship to the deceased? ~ cU~ y-- In what capacity are you acting? ~~.f\ ~~Li If attorney. name and relationship of your client to deceased - Straub, Catalano & Hc'llvey Funeral Home Date O'd~~\ ~ Signature of Applicant I,. Address of Applicant !'i!'i 1-:'I:'Jt ,Vldill 51lU;( l~O. Uo.'{ 131 '.Vappltlgcrs f8IIs. N.Y. lZSOO II. H" H'. .., HHH ... H" . HH.... . \ . COMPLETE FOR DEATHSOCCIJRR NG\ASOFJAN.' I ~ Number of copies requested with confidential cause of death -1'- Number of copies requested without contid ntial fff!~rnW'~{QJ ... ...... ........p.. FEASe.p'R1NT"NAM'E'.AN. 'O.H' :::<:>::::>>:::::?(\ ;:.:,~ :.< " ,'.'._ :\"::'_ :.1 . ..; ::). '._:- '..,..: :.'::;':....:,:" .::' tbae:ssNT:\'(/: . .. ..,.....' -, ....... Name Address City State Zip Code nOH-?94A (6/2000\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ........>...........:PLEA,SECOM PLETEFOFtMANOENCL,QSI$FEE <. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ......... .. ...... 1~..OR ...> /........... ........ .. Name of Deceased ~VW\,~ \rwrn Date of Death or Period to be Covered by Search ~~ ~. ~3 - \ ~ - 2-D \ z.. Fust Middle Name of Father of Deceased Social Security Number of Deceased ~vuJ?\:- 'DIA~D'\S It) S--'~ - I eoz- First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~~\ YYlPrn' ~ Lt ~ '4).~ 8<..0 First Middle Last Month Day Year Place of Death W~p'I~~~ ~ WO-ff'I~\,8 ~l8, ~C\ Name of Hospital or Street Addres ~'Town or City County Purpose for Which Record is Required ~ DVll+e. ~~\~ What was your relationship to the deceased? fl.AV\.Q-~ ol.J r-e ~ In what capacity are you acting? FNL~P-~~l'1 If attorney. name and relationship of your client to deceased --- - Signature of APPlica~ ~ .;\.~ ~ Date 3- 19- ').....b\l.. Address of Applicant ~~.~. ~ S \:V'" e \.:- \0~P\7Lg ~ -U1 \ Z-0b \ . .. ...........cOMPLETE .FOR DEATHSbbduRRr..d'AS'OFJAN '.Afi"';:1it198S:\@:'})?::::')}\)"::':(::'. ... I b Number of copies requested with confidential cause of death -$- Number of copies requested without confidential cause of death :.................i:.'{PLeA$E:PRIN.tNAMe:.AN04XPORE$.$AMHERS:f\$CORP$HOU:Cpae$J;Nl\))){U\:::; .........s.. ..... ,". .", ..-, ..... .................,...........,.........'.'.' Name Address City State Zip Code V nOH-?94A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record ... H......... . .' :;:.,: . :::'EEr'::::;::&::::::::tt:;U;;;/;;:;;::;:::::/:::mf:itt;((....... .................w .................. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased GorcAf) 1\ First Middle Name of Father of Deceased rYlc WVt~ Last Date of Death or Period to be Covered by Search 01/")01 \2 Social Security Number of Deceased First Middle Maiden Name of Mother of Deceased Last First Place of Death ~X) O~~~r"\~Jt\\ ~ Name of Hos ita! or Street Address Villa Purpose for Which Record is Required . t-0YS Q 0 l ~ ~e ~\,o--.\- Middle Last Date of Birth of Deceased O~ 2:2 Month Oa \q(6 Year Age at Death i.f~ G)lv~ Coon What was your relationship to the deceased? In what capacity are you acting? P () \ ~ ot. c:J:(.. u __ If attorney, name and relationshi your client to deceased Signature of Applicant Address of Applicant Date Z{l..J-I! rL Number of copies requested with confidential cause of death . _ Number of copies requested without confidential cause of death Name Address City State Zip Code ~H-294A (6/2000) OLYMPIA CLOSING SERVICES, INC. 2240 Palm Beach Lakes Blvd. Suite 400B West Palm Beach, FL 33409 Main: (561) 689-4481 \1N6P. (5~'W689-4491 Ms. Christine Fulton Town Clerk Town of Wappinger 20 Middlebush Road Wappingers Falls, NY 12590 RE: Ronald W. Klaproth, deceased - Death Certificate 2840 28th Way, West Palm Beach, FI 33407 Dear Ms. Fulton: Enclosed please find: 1. Application to Local Registrar for Copy of Death Record for Ronald W. Klaproth; 2. a photocopy of my driver's license and State Title License from the State of Florida; 3. Copy of Warranty Deed into Ronald W. Klaproth and Linda M. Klaproth and copies of two mortgages; 4. Copy of Final Judgment of Foreclosure of Mortgage; 5. Copy of Certificate of Title into Adrian Castro; 6. Copy of Authorization Letter by Adrian Castro for me to act on his behalf; 7. Copy of Title Insurance Commitment requiring status of Ronald W. Klaproth; 8. Copy of Obituary of Ronald W. Klaproth; and 9. Olympia Closing Services, Inc. Check #1059 in the amount of$IO.OO. As a Florida licensed title agent, I hereby request a copy of a Death Certificate of Ronald W. Klaproth, deceased to clear the open title issue of why he was not included in the legal proceedings in the foreclosure of the property located in Palm each County, Florida. Please note, this request is specifically for a Death Certificate with NO cause of death. Of course, if you should have any questions, need additional information or if I can be of additional assistance, please do not hesitate to contact me. I thank you for your anticipated assistance with this matter and hope to hear from you soon. Sincerely, /cmh Enclosures ~\ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record ....... ... ....}...<<......................<.....H<~t.sA$eQQMatJ;m$JEQi~U\lI't~NPSN$4(),$Sr$$<)})..................... .:.:.,.:.,.:.:.;.:...:.':>.:,'::.".:.:.:.::::::::::::::::::::::::::':';'.:::.::::::::-:':-' '.:. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~L~IRE C. BU(?KE ~ PI~teE" First Middle Last Name of Father of Deceased Date of Death or Period to be Covered by Search .:1- J7- /;;J., Social Security Number of Deceased T40"" 45 First Middle Maiden Name of Mother of Deceased CJITHI3f<INC MI7LONC'! First Middle Last Place of Death / 0 (; 0 LD R j) (!11.5U III Last //&- -:}~ - /59'1 Date of Birth of Deceased ..3 II 3~ Month Da Year Age at Death '75"" w /1 P r'/ III 6/:12.. DvrC#E55' Name of Hos ital or Street Address Purpose for Which Record is Required Count To S61TL€ &STI17'"/F What was your relationship to the deceased? FUAJFR-~L ])/ JeEC-.-rolL- In what capacity are you acting? 5;9 fI1 e If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant Date ;;l ~ ~ I - / '2- >)COMPETE:FQRO'ATlidso.ccua.RINo.:iA ~ Number of copies requested with confidential cause of deat - Number of copies requested without confidential cause of d atJ;'OWN OF WAPPINGI;R TOWN CLERK .................<...)................................p:.L. .....eA.'.: '''S'''E'':''''p''S.'J''N''''T::''''''N'A.'''''M'' .E.....;A. "'N' O:\'A"':O',".'D, '8""E' 's' :.'S""W' .H""E''''R'e:''''R' ':E'''''O",o. ::"R.' ':D',.':;;'S':'.H'.."'O....U,'.L';::.O'.......S'.'E' ""'S'.E'.N' .T'.....::::..........::::.......::::::::....::::...../....'...................,. . ..... ...... .". . .....". ............. . .'.... , ... " .... . ".. . ,",.. ., '. . .. . '" .,. .. ," ",. ... . . ........ '" .. ............ .......... .......-:.......;....'..;.':-:.:-:-:::::::-:::::..::::-........-:...........:::-.-::::..::.:.:.:;..;:.::::::.:-....:-...........:::..:-...-:...:....:::...:.......:....::.::...... ..:.....::::..:..::.::......:-.:...:;:;.::..........;.....-:.::-......::::....:.;:.......:-...-:.......-::::.........::;...........:'.;:..::::::;::-:.;.........;.'.....'..... Name Address City State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Cae.>' of Death Record .. .. ... ... . .:pLeASe:COMPLETEFORMANOENCLbSEPEE . ............,.,.., "...,...:. ..",' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ ~r\~ Fllst Middle Name of Falher of Deceased Date of Death or Period to be Covered by Search \J',~~ Last 2-'~-rz... A~~ Firs( <=1, Middle ~~~I'""\ Last Social SecLlrity Number of Deceased \8 \ - 20 - ca2::.~ q Maiden Name of Mother of Deceased 1?V\i-I~ Last Date of Birth of Deceased K>~it \ Middle \ - \~ - ~~ Month Da Year Age at Death .,~ Place of Death :zo Src..le..... ~n~ Name of Hos ital or Street Address Purpose for Which Record is Required ~ Count ~l~-P L.~ t\-{t~ What was your relationship to the deceased? = ;p:.... c-~ . In what capacity are you acting? <::V\ c ':5 If attorney, name an 'onship of your client to deceased Date 2- 2'- \2- Signature of Applicant Address of Applicant ~ ,3>\ I lNo-FP\~ ~~i f'!'i t2c;e;6 ..". ...... ..... ......... COMPLETE FOR DEATHSOCCURRINGASO umber of copies requested with confidential cause of death 'h \:pCi;Asa,PRI.NTNAMeANPAOORS$$.WHER 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 "FORM.AND" NCL.OSEFEE',' . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE"PRINTOR TYPE Name of Deceased Date of Death or Period to be Covered by Search Gorana McHugh January 30, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Goiko Spasenovic 406-27-1491 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Vera Vanie May 22, 1966 45 First Middle Last Month Dav Year Place of Death 8t; 0 ~borr\c l-h \ \ ~oo.d Wappinger Dutchess Name of HosDital or Street Address Villaae. Town or City County Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. If attorney. name and relationship of your client to deceased Signature of Applicant ~ c.a.^.~ Date February 11,2012 Address of Applicant 895 Route 82 Hopewell Junction NY -L.. Number of copies requested with confidential cause of deat :: .... .. , t..:. . . .' _ Number of copies requested without confidential cause of Name Address City State DOH-294A (6/2000) , .A,i... "'i.-.--., '.~..-, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record .... .:PLEAse:coMPLETEFOFtMANOENCl;OSEFEE'; '.::;.:.:. .:..::...::. : '." ':".,:. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ Middle Name of Father of Deceased ~~t ~I~ First Middle Last Maiden Name of Mother of Decease~() ~. t'.Ut U-c.L First Middle Last Pla~e L0O{JP~ 0UV> Name of Has ital or Street Address Purpose for WhIch Record is Required ~l) k llJt~(fS .:.,...:.......::./:PlEASEPRJNTOR Date of Death or Period to be Covered by Search ~ d- -\'-{ - 6-D I d-. Social Security Number of Deceased OqO-1 ~ -~qLj~ Date of Birth of Deceased ~ ~ ~ ~ t 9r?> Month Da Year Age at Death '88 , Town or Cit D~9S County What was your relationship to the deceased? ~~ c;l i r U~ In what capacity are you acting? eN'-.. ~ ~ ~ rl1 If attorney, name and relationship of your client to deceased Straub, Catalano .".: Ilal\feY 55 East :\lditl StH'~'l .. 1'.0. l~ux U J .'1 Wa in 5ers Falls, :-;.Y. 12590 ~ Signature of Applicant Address of Applicant . ....:::.:.:'COMPLETE FOR DEATHS'O'cclfR:Fir:'Q::AS'OfiJAN':" .......:;.,.f.P198.s:\;::.D.\//:"=:::;::.':::}':t::::.:\:0""i': ~ Number of copies requested with confidential cause of death 1 Number of copies requested without confidential cause of death ~~cc~~~~Ud) ....... ......:/:.n(.pL.~A$E':PRI NT'.NAMI;ANO:ADORe$S.WFii:REFl.SCORP'::. Name Address City State Zip Code OOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record '. """""<PLeAsEcoMpLETEFORMANOENdt;oS'EfFEE: '.:,' . .....'.:..::.:.,/..:>:..,....;..... <::.,' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. '," ...,..",.... ........... -.. ..... ....,.....,....,...-.........-...'...........,-..-... ...-........ ,...... ....... ..... ........ . . .............. ...PLEASEPRINTORTYPE) .. .......:.:..... . .... .. .. .... ...... Date of Death or Period to be Covered by Search r-=-e: \0 . ~, 2..0\"2. Name of Deceased ~~~ r-:. Middle Name of Father of Deceased A. V\ 0 ~ l\' n.0'... First Middle aiden Name of Mother of Deceased V , V'\ c.e.n "0 1::::\ t-.-\o..~ ~(~ First Middle Last k~~ ~\'Cc.I'nVlDl.... Last Social Security Number of Deceased <!:) ~e - 0 \ --90 \, Date of Birth of Deceased f:;:.<:o. 'S I '~Ie Month Da Year Age at Death ~~ Place of Death ~ \o.V't Ci2- W.,...~\ "'&~ ~ ~ ":::::. Name of Hos ital or Street Ad&ess Purpose for Which Record is Required . svl ~ L~ ~ A~~i~ What was your relationship to the deceased? ~~ , ~ , C'""ec.-1'ttc.... In what capacity are you acting? ~ 6--\,..,.-.., \..p c:>..f' ~t.y\.,' l ~ If attorney, name an~hiP ~f your elientto deceased Signature of Applicant A ~ ~ Address of Applicant to ~ \~l 1 ~ t::: ( ~~\~\l~ i a Town or Cit bu~~s Count ~~D Date 2-(g-Q. . ..' ....... ....)i'/:\f98S';/t'n;:j},:':?::::'n\':::::':':in':::.:...q::;q:o::;.,?' . .... __ Number of copies requested without confidential cause of death ... ........;i....::..';.;PL,;ASE..PRINTNAME;:.:ANp:ApORE$$...WH~RERI$C;ORP:$Houtbae:,$I5Nt:,\'?::::.:\\i(::::.:::\:: ... Name Address City State Zip Code DOH..294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record :jPEEj"ttt:M':\t::'/"j'{it:t)'itt:::\"iM FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased First ~c,\\r\L: t.... Middle ~. Name of Father of Deceased First \J {' \ \ ~"'^" Middle Last ~ Ii r ~ Maiden Name of Mother of Deceased First ~( 0rt \- Middle Last S\Mr Place of Death ) ~ (), Q ,) 4" ,,\ [ ~{\ 4'D Name of Has ita! or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search Last .:r'vl (S L -l-\2- Social Security Number of Deceased o 7 r - J 6 '. ) ~ [G Date of Birth of Deceased Month:3 Da ) r Ye~/ FfA.t\s Age at Death bb 1)v t cle-%' Coun What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relati h" our client to deceased Signature of Applicant Address of Applicant 16t1' J Date 2-2-/2 fune..y alP C':y (J .rYY'---d1nn . StJ UICt...S. - I I I I I I I I I ! j ! I I I ! I I 2- Number of copies requested with confid~tial cause of death _ Number of copies requested without confidential cause of death Name Address City S E.B - .2 1'0\1 t - w ~p"1.NGE.R -rO'I.J':O~N 5-~R\<. .-----.--.--- DO~ (6/2000) >, 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 First Verno/) Middle Name of Father of Deceased ~CZmfAi ( First Middle Maiden Name of Mother of Deceased . /Il~u f {(/n t 11/1 FIrst (Middle Last Month Os Year Place of Death'l (J ~ / S {p () 12 Ie. ? ~ &.4 am vi( I d- gf Name of Hos ita! or Street Address Villa ef Town or Ci Purpose for Which Record is Required t M!J)u ~ 111- What was your relationship to the deceased? --11-/;#r-4 el( S' ftr ~ In what capacity are you acting? ~rne~ S . . -f1- f If attorney, name and relationship of your clion! to - fe ~ Nil t /.. SIIVc4 n ,i2t! 7 Signatur.oIAppliconl (I~ fn-I..M; /(tZ1r j ttc.rJfC/ Dato rJ (,) r/ If;).. Address of Applicant L Last {jJCA /fJ~l( Last Date of Death or Period to be Covered by Search ula?l!f Social Security Number of Deceased o ~ tf ,-;;)0 -.35:7'/ Date of Birth of Deceased I a ~ cd7 Age at Death f3 ~ /zAMJ Coon Name Address City State DOH-294A (6/2000) f1 V ~ {;J o/Iu- fthJe, ~ v~ Wa.y W dAV' ~~ ~ ik ~. ~~ 0-- crLlu Ir tv /t-AfJ UfJM ~~" ~~' 1m~{!'1 ~J.~ ;) 7J JAtV AI ~. SLf JH /;Lt{)/ 11 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record ......... .......HPIiLEAseeOMPUI;1l$.:f;QAM'ANDENQCQSt;PEE.H'."... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name).Dece;;bJ E! Firs~ n Middle Name o~ ~ther of Deceased ~ ~ypr/rYlU1Middle UVJ~ Maide~~+b~~of De76rl~~ First Middle Last Place of D17 t1lM a:I fi k /lYJ ;11 Name of Hos ital or Street Addres':'c.rr Purpose for Which Record is Required Wddly Date of Death or Period to be Covered by Search CVa~ f;;S- tlJl/ Social Security Number of Deceased 011 ~ ~ - 4/73 Dat~h of/5as~ Month Da ~ Ag~ath What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your Signature of Applicant Address of Applicant 1 Number of copies requested with confidential cause of death (R{~~~~Vl~(Q) _ Number of copies requested without confidential cause of death ':")~I!'~'? Name Address City .:..Pti$.4$SfUlINlfNdE::AND:uaae$$rwaeSEJI$QOJ[ State Zip Code DOH-294A (~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe)' of Death Record 1F.ES'JiJiW:ifWW))"'{',fi}i:)"i{ffi""'i:i(i{'},':{ii:{' .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased R.otl~ First Middle Name of Father of Deceased GLClreflce... First Middle Maiden Name of Mother of Deceased GtcL ~ lTcX-t e First Middle Last Place of Death. 50 HU1~ St, Wa.pP1VL5e+S Name of Hos itat6r Street Address Purpose for Which Record is Required ..:IJ1SWt:U1 ee. ;;0/ ( re f.#J h"tS~ What was your relationship to the deceased? ci t1l.L~ hJ..er- In what capacity are you acting? If attorney, name and relationship of your client to deceased \}J, (fulclX)L,vell Last Date of Death or Period to be Covered by Search SepbvLloe.r ~I 19.CZJ-.- r'Y\ac1bwe. cJ Last Social Security Number of Deceased Date of Birth of Deceased '1 ~3 ,'1,9 Month Da Year Age at Death /d.. fukJuSS Coon Signature of Applicant Address of Applicant ~r~ ~ t!A.2Ib fo~1~ A/Y Date 02 - I 7 - /eJ. I ~s7 t) _ Number of copies requested with confidential cause of death . ;L Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) Jf v NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. N~~e of Deceased 11 ~'~ \ r\.aj ~ a:ACe First Middle Name of Father of Deceased ~t~ if L d.) ~L f'tl/t ,..,C/~ First Middle Last Maiden Name of Mother of Decease~ t.. r9 &-IrA /) 'jZ t9 TZ e/Z First Middle Last Place of Death et'?#Y?" ~/"'Z/,..,. /..qr1'l{' Name of Has ita! or Street Address Purpose for Which Record is Required ~l.A MS"'~ Last Date of Death or Period to be Covered by Search nY .. I t:R tJ(1 9 Social Security Number of Deceased o re, I - J" - J~T' Date of Birth of Deceased Age at Death t::Jc{ / {, I tiN Month Da Year 3'1 ~J;.....I'.J Coon fJ~"K d~cC"7. t::h4t-'J What was your relationship to the deceased? ~;c/ In what capacity are you acting? If attorney, name and relationship of your client to deceased Sign"". 0/ AppliClllll ~ ~ - Z _ Address of Applicant ~ 4 ~ ~e ~e:;~ t:. 1S~~ /1'1~,;t?" Date .#-It:::.. ~/z.. /yP t::7$~Z, 3-. 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~ D2-5-d-DO ~- ; ~. ,. t 1 ( i; t ( t'. ~ ~. t ! .( NEW YORK STATE DEPARTMENT OF HEALTH Vital Rf~cords Section Application to Local Registrar for COe)' of Death Record .. ............. .:Pl1;ASECOMPLETEFORM ANOENCt,.;OSEFEE<:: ....... . ... ... . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~hc==\ \~ \N . Flr~,t Middle Name of Falher of Deceased . .. '.. ................... ................::PLEASEPR1NT OR Date of Death or Period to be Covered by Search ~Y\ 2'-t, ~\ 2- lN01~I' Last 5 ;\ ~~I1-z- Fir~ Middle Last Maiden Name of Mother of Deceased \ f...1ar\ cri<=-. Soffb\c Firsf.....) Middle Last Place of Death & ~ Si rc:::.e.+ Name at Has ital or Street Address Purpose tor Which Record is Required t=:hJ C5-P Lt~ ^~,.~ Social Security Number of Deceased 108 .... 2b - '2.2.(0'1 Date of Birth of Deceased "loJ.8, \<138 Da Year Age at Death Month .,.~ ~~ Count What was your relationship to the deceased? In what capacity are you acting? ~ k:e.... ~\..p. If attorney, name an . nship of your client to deceased ~ner'b-\ ~~c.~ c:rP ~VY\ ~ Signature of Applicant Address of Applicant .: COMPLETe FOR OEATHS.bbCU'RR....GASOFJAN ....AR..}1.:/1'98.S.\::::/:::::::,;:::/::::::: :.::..:'.: ...... . ... ~umber of copies requested with confidential cause of death -- Number of copies requested without confidential cause of de ~U~~{Q) Name _ Address City __ State Zip Code J NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 I Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-lD: -OR- B. Two (2) of the following showing the applicant's name . Driver license and address: . Non-driver photo-ID card · Utility or telephone bills . Passport · Letter from a government agency dated within the · U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Timothy J. First Middle Date of Death or Period to be Covered by Search: (mm'ddlyyyy) O'Toole 088-48-6365 Last Date of Birth of Deceased: Age at Death: 01/10/2012 From To Maiden Name of Mother of Deceased: 10/01/1954 57 mm/ddl Death Certificate No.: (ftknown) Catherine First Name of Father of Deceased: James M. Middle Steigert Maiden Last Local Registration No.: (ffknown) First Place of Death: 11 Daniel Sabia Drive Wapingers Dutchess Name of Hospital or Street Address Vllage, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with :\ Copies requested without Total number of confidential cause of death .J V confidential cause of death copies requested Purpose for which Record is Required: What is your relationship to person whose record is required? W. Middle O'Toole Last In what capacity are you acting? Funeral Director If attorney, give name and relationship of your client to person whose record is required: :9S:i ant Address of Applica Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, you must submit documentation of a lawful right or claim. ~;lhSign~~ Year .' . '. '.......11tAR.. US. ONLY 01 2012 T~lif~iD: ~lOaId_tQ__1 O,~,ucense . . .",,~. ....on..:. Sean Doyle (Applicant's Name) 371 Hooker Ave. (Street) Poughkeepsie (City) NY (State) 12603 (Zip) Type: Number. Type: Telephone No.: )(845) 452-0460 DOH-294A (06/2005) ~y \1\ \\\1,--' j NEW YOnK STATE DEPARTMENT OF HEALTH Vital Hf~cord$ Seclion i .... '-:'7 .; "; ""PteAsECOAi!J>LETEiFORM 'ANOfij'lCI,'l'lse iA:e""""~"X0'K'''.:) .iW,..." .;:v.;y .'V Application to Local Registrar for Co of Death Record fEE: $10.00 pe. copy Of No Reeo.d Certification. Please do nol send cash o. stamps. /\lam,,} 0/ DGcQasod ~ Fl/:;/ ttddle .-----., Nanw 01 Faille' ot Deceased , r~ \~, ~lJ Fust Middle Last Malden Name 01 Mother of DeceaseL I I Y\Il ..~ S, 1 \ l)~ 'f1/~ Middle Last Placo 01 Death ~ ~wJLt.L 12.0~. Name 01 Hos lilal or Street Address -. Purpose lor Which Record is Required ~,of \;-tt. ~t'vS · :; .'. ;.; jib}.:;,'"'''''};''''' :'f' LJ:'ASEPRI NT OR '1'YPEi'0;;VW?;"1\0:~VJP<;ij.'Y';j!i:N0i.'!Hiij:""i;.;;; Date of Death or Period to be Covered by Search ~~~ Last I-~-IJ- Social Secwity Number at Deceased d-I tJ -( B -~ 't 92- Date at Birth ot Deceased J- Month )Da }..y Year Age at Death t8:r- WI'WI was your relationship to the deceased? In wtlill capacity are you acting? V\\._ /I attollley. name and relationShip of your client to dece'lsed Straub, Cl/cllil/lO s: llalvey SignCllulI:: 01 Applicant ,- I I '., " Add,ess otAp'/Jllcdnl I., il." III II~-'---'- .. -Lo- NumoClr 01 copies requested with contidanti'll cause of death - ct.. NU"'''er 01 copies requested without confidential causa of death I.~ /J- " '~(;:!f:;ii!:}Pi:::)h!t:::tH}f::i??;:\~::)kt?{ik::i:+.. c--2-- . ...... .1i:;;X<it?WASIlPRIN:tiNAMetAiilblAbDliESS';WHERE'RECORO'SIlQUCIX1iIEU,eNTI-"'1S'~lm Nam8__,,_.___ Add/ess CHy ....u..~.-~~~~=~~~ State ~ Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coe.v of Death Record ~:_::;\=i:ri((::~})r:::rif::::}(J:)J):f}::l:::\\:::f:::::J(:q FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased TU()C!.-/!I1{}e.- MQr,'tl..- First Middle Name of Father of Deceased 4/110 n; ~ McAI-:o<<;o First Middle Last Maiden Name of Mother of Deceased M I' cl t!.- I " n Last Date of Death or Period to be Covered by Search &\Jove M b~ -:l.. l ;Z 00 7 Social Security Number of Deceased Age at Death '5LI First Middle Last Place of Death \- 0 fY'} e-. N Y/ l;) s-q 0 Ou fe hes-s Coon Name of Hos ita! or Street Address Purpose for Which Record is Required V2 What was your relationship to the deceased? vt1. 0 I-he r In what capacity are you acting? If attorney, name and relationship of your client to deceased Sign8lur.ofApplicent.~4A ~~ Address of Applicant ;l.. I C ~ If 0/ I Dr I" ve Date //31/1;( ( I { JAJ wCf,r~,'nSers Pal ~ pv r 125-90 -L Number of copies requested with confid~ntial cause of death _ Number of copies requested without confidential cause of death Name A(/, Iho 17 V f( pvt" chelr i'7 Address -;;z I cd lID I ( (] r,\;e WCtRf?/ f7 .5 t: r S City LJQrr\tI75f'r~ PC//5' ' State 'tV Y pc/IS Zip Code 1 ;;< S-- ~ 0' jf DOH-294A (6/2000) I I I I I I I I I i I , I I i ] i i I J _...._~--- f1 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 ft I_c.!' ft- Lvd~oI') po { c.t:;-l\ 4 r (;Dry' First Middle Last Name of Father of Deceased Date of Death or Period to be Covered by Search Social Security Number of Deceased First Middle Maiden Name ~ Mother of Deceased tLOQe.Y S First J Middle Place of Death :-... U. d- S~ l.,)n'-.Je.... Name of Hos ita! or Street Address Purpose for Which Record is Required Last Last Month 6 q Da 0'1 ff31 Year Age at Death S-i) Date of Birth of Deceased ~s.S Coun What was your relationship to the deceased? (hom In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of APPlican~ Uv~ Address of Applicant ~30(f)o{1 Date -L Number of copies requested with confjd~ntial cause of death _ Number of copies requested without confidential cause of death Name Address City State Zip Code ~ J DOH-294A (6/2000) .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for eoI!)' of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .... . :::~:~:::::::::rrf~~j;~~fj~~;r\ffffrrj~fr!~rfit~~~~;;~~;lr~j~~:~~m~1i~~~t~)!rr~~t~~~~~~~~~~~j;1m111~;~~1m~r~~t~~~~~~i~~1~~~1~1~~~1~. .;.' :;: '. . : .R :.:- . :~~*~~~~~~~~~tt~~ji~iij1ijiiii~!jmt~!iri~;~mt~t~iijjjWj~j~~jjt1~1~1~~~j~~~~1~j~iijt~i~~1~i~~1i~~rm~11~~?~tffft~i~i~!!!iiJtf@rrtt~~f~ Name of Deceased A'( ~ol~ First Middle Name of Father of Deceased LOUIS First Middle Maiden Name of Mother of Deceased Selffi~ First Place of Death II LD l' 'lY\ Uf Name of Has ita! or Street Address Purpose for Which Record is Required Lt n c: \ (;( ; (VI e d, b Ct () \~ R Date of Death or Period to be Covered by Search o th Y'rIt(~ S e p +. 5\ 200 () Last Social Security Number of Deceased Ro+h f'rll{ f) Last Middle Last Date of Birth of Deceased ~ 'd-~ Month Os 4-6 Year Age at Death 156 c+, VJ C1 P p ,-n9~ (5:. \=(A) I S Villa e, Town or C' D IAtch..p ~5 Coun C\cc+. What was your relationship to the deceased? 1--\ u S loa () d- In what capacity are you acting? I ~ If attorney, name and relationship of your client to deceased () Signature of Applicant Address of Applicant , ()...., C) Pu~v ,A-e vU La 0 \) . .......... ........ _ Number of copies requested with confidential cause of death . ~ Number of copies requested without confidential cause of death Name ~ LA f DC\- (0. Ko-t ~ ~a.. 1"\ Address 76, Po n~ v,' p vU I 0 0 p City \..U (J f' f \' () 5 -p ($ ~ 0 U So State ~''1 ' ZipCodeJl:5 CJ 0 DOH-294A (6/2000) .. ;;'u iJO J v ~~ I , , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe>' of Death Record ~ \ \ >PtJA$.E,OOMeW..f,:Olur..o.efan:;;QleFeenn .. ......... .......... ....... ............................... ............................ ........................ ..................... ................. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Npme of Deceased L.At,ure.uc.e e, Wer(ler R~ M~~ ~t Name of Father of Dece~d \-JlvJte",c.e. t" I We/'{:>er First Middle last Mai~f'=b~~her of Deceased kt9PS R~ M~~ ~t Place of Deatha_ 11 .. ..... _ .. bEt. €.qso n Lo.Ne lX.J~ Name of Hos ital or S;~~t Address Purpose for Which Record is Required , FAM~~Y R v.es!eJ Ccp.i!S Social Security Number of Deceased t!)~bl ~ (;,0. ?98{J Date of Birth of Deceased Q'( DS Month Da 19" Year Age at Death ~.q"f"N ,,!r , town or SO WC~e.sJ Coun hLA.r,'..., 1If'!,'IIruye"'~ ~Wee - Number of copies requested without confidential cause of death n::::::PWe4$epR.Uiint""E\gffQ4.. .:. ::WHERE/Re. :...:....DW"Q.Ql.;p::.e$eNT::\ . .. ....... . ...... ." ........................................ ...................................... ......................... .............. ...................................... ......................................- . . . . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . ......................................- .................................... .............................-... Name Address City State Zip Code u.j t?--I IL--- ; /} I DOH-294A (6/2000) NEW YORK STATE DEPARTMENT-OF HEALTH Vital Records Section AppU-cation to Local,Regi$trar - for COe>' of Death Record' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :~~~{~~tt@i~iit~~~~ii~t~~iiJ~1~;I~~~~~ffil~~~i{ti~ffif?~j~!tft~rJ~ttti~i~t1t~tI@ffJ~i~~~1~~fi~~@~ifr:iii~i~if~~if~ .:.. ~ - : ,(_" 'f:b ,,~ -:= :-:: =::ttt:(=t::ft::ti((:tt=:::r::t:'f@tt::t,(,::!=!t:t'::t{t::t:!::=::t:(:tr=:trrf:t(((m:(@t~ Date of Death or Periodto be Covered by Search /1 11/1/ Social Security Number of Deceased Name of Deceased ~nU:- ~ C First ' Mtddle Name 6f Father of Deceased ~~~~ -~ First Middle Maiden Name of Mother of Deceased tJ02~ LaSt t-Je ~r.fl-- Last First Place of Death Middle Last Date of- Birth of Deceased :5 2'-1 (,1 Month Da Year Age at Death S--o -Du7Z--hQj Coun ~ C 4!.rJnz.'\J,r,' Name of Hos ital or Street Address Purpose for Which Record is Required Q~VL What was your relationship to the deceased? _ - ~ LIC!-- - {)/~w In what capacity are you acting? _ trwv [:-r~W1 iJ- If attorney, name and relationship of your client to dece & _ 1.L ~!115'JL ~(b Villa e, Town or Ci z:,J"~~ '1,f~ Signature of Applicant Address of Applicant ~ ...--- }C6 W1 - _ lI) Date' '1,/2 ~~~~~~~~f~~~~~~~~;~~~1ti~i@*~~~~~~~~~~~l~~~~~~~~~~;;~~~f~f@~~;t1~~:"':+;" .." . .~.~.....t... . ".....;;: ~:.{< ~.:.::~ r . -L - Number of copies requestf!d with confidentialoause-,of de8 - ~ Number of copies requested Without c9nfidential cause of d ath [R1~~~~~~1Q) ~:~~ z~l~~~*~Wf~~*-~~:~~~~:~&~t~~t~f:~~i~~ .- 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. Name of Deceased Mary K. First Middle Name of Father of Deceased John First Middle Maiden Name of Mother of Deceased Francis First Middle Place of Death , Wappingers Falls 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 Sonntag November 22, 2011 Last Social Security Number of Deceased Nally 195-30-6091 Last Barbour Last Date of Birth of Deceased 3 30 Month Da 1939 Year Age at Death 72 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 relations :;2our client to deceased Signature of Applicant \ .--:; Address of Applicant 1028 Main St., Ish 'II, NY 12524 Date December 27, 2011 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 WHER Name Address City DOH-294A (6/2000) -. App~iiGation t.o LOG.aif',R'egrstt'~1 I\Jt:yv.~(c:I..n( 8~ATl:: DEF'AFTfIVIEJ\IT OF HEAL.TI..j If'" CO~J\Y of Death Reea! c ~1"'1 1'(,leUI cis ~)l'!cl:lon I 0 ~ '"' ~~_......... IJlt~IIMUHf\I..,..m"'Ull~------"""HIllIIU'lIl1"lIl~~iJAAtUmlj:l.l~l.lMNlWIIlUIUI'&UUVJAll'.RlInJW1~~*a.I".lAl --...-.....-- -'.--.- ....-....----..---..-.---..-:-171:1..-/= /'\-:CS'-I::-C'C')jVI-I:li-::I=:.T'~I:::r."(-)"I:IIV-1 -';::'/\j'D' FI:iJ.C:LOS;E-'PE1::,.," .'~:. ,.,.: . ' .......~'~._........._--..... ._..:....-:....=~~..::_~----..::-:.-=--E:.:.!.:.__. . ,'"1\ -.. ___ '.:'::.;':::":::::i~ ;;::~:~::::(':::': ~; FEE: :1>.10.00 PI'll" copy 01 i\jo Fll:!corcl Cl:)J1:i'l'ic;ation. I:'18EtS8 cia not send cash 01 stE\lllps. _J --- .__._--._._.h...._-....__.."..,._--......_.._._..__..._~__,.__....._-.~....,.......--.._....-...~........'......_MW....._._............_....._._.___~... 7~::::::C.-:2~Z;~~T~~:.:..:-"'-c:::;':.77'::';:-:~.:,:~~"';~.~::::p j:E;'A1;i:j:::":I:rrihrr:6iTT.Y:R:t> ...:,'.':' :.' .::..: ':':::);-'::" .::\":i:':'::.:' ,.::::::::::::::/.:?0F ::'::'::::kU ~. :;.:~':::~!:,,:.::.: i~;;;;;~.:~D,,~~;~~I-'-'--'-.--~~~:'-'.'c,--".'''''-o;;t~:, ;;~~;h or per; ad to-be Covered by Se<.roll [JI/ULrMc /11I- 1-J U6Hf"S ---...,-...E!!?!.__ Miclcllt::> Lcl~;t ])E(L :21, ~oll . 1\/ i:) In U Df F "1ll :;.~~;::.~~j..i:)~~;~;.i;~~d----.--..".....,.._...._..:._.......-..-.--..---- .sZ~~~~ ~) I:J ~~I rity !\J L/I; be I' o'f I.) e c e as Ii! cl fJ(l)[)(ew d.V'-L1 c::. . _ :"f' . rrv....-,l; / 05/f' 3D _ c::,~~ . ......--...!"'~'2!____._ Mlclcllo Lmjl ___._ ____,_~_..-- Mrll:~~:~~~rJtI101~I-O;~~;~d~~:~~:---[~rt~~tI~E~e"~a;ed /9/1 I A~;Deatll -~!~~~~..-,,----.-~'.!~~-_._.__ _ Lm~'l Month D~~~eCll' F'IdC8 U'11J1~tltll ELF/NT 117 W;~;~~6-;;;;..-_;;~~~-;_..--_.._- . wl'I-tp/Jnll6E;!S FlluS J~~~~.~l~. ofJ~:loE;pilal 01 str~!et ^clcI/'(~~,:~l Villt:1qe, T~;a,vn or City 1:1 1I1'posuloI \rv;;r;-j::i~'::';;d-i~"n~~~~i"'-'-.-'.''''.-'-.'---''--'''--'''---- YuT4I&5~ County _~._ -_._._.. To '>~T'Tl.E B ,1lJ€" __.__~---- . .._.__.......__._--~-,..---_._--_....._,...~.._...h__---.__..".........,.,...__._"_.....__......._._....,..___..__.._._~_.____.___________..._____ VVl"iul Wi:1.~; YOL/I' /(jlaliclllship to I:I)I:~ c1lJCE:li:lsElcl? ---.-E.ud~._.~/~ec-7"'~_.__~___.--_.~. III Wlli'll cl'lpacity 811:;') YOLl i:ictin9?_____._..SL;;.M..t:::-.____.___.._____. _______.____._-- If allal/Hc)\" Ili:lll'J<:! i:lI'lCII'OIEll:ion:)/'lip of YOLlI client to clr:!(.:oasl~cl ____. ....__---.-- ~;iD~liJ~.I~.e,'OI Applici'I/TI -~.il..~.__ Date...,(2..=..;2.8.::zL----. Ailello"s 01 APpllc:(lnl..-'-=rL.I1ttb...L..~....w..>1..eAakd3?~ii~~-= ..-- --.-...---..-.-.--.......----.....-...-..--.--.-..-.......-.-.-.----.--.-.---.----------..-.-.--.--... . ..---..---.- ''-.?-.c.::~~;J:;?Cj~i4fR;fQg~f~~icu.8!liN~IlSDF:clANUAiiIT'Jl9a:~i~':q,2'" '.':: . ' "! ......-..-.: l~urnbDr 0'1" copies IW/l-'l~sIJxl with c:onl:icll:lITl:ial Ci~W;lj err c1eath . -'-..-... I\)urnlwr of cUpi(:!~l l'eqLle~;tlxl without con/:iclelltinl caw:;e 0'1' cJeatll -....."".--..-......--.-....".-".-.....---......---.-.--.......-...-.-...--..------......-.-.-..:..:.----..---...-:-----.. '. , _...-.._~-~-,~..-.:-;: ~', .:: ...'..:;~...~...,~~:._.:'~-.:::..~.....'F[:i'=7x:~;.j~~:.lRTt~T":f.ll\iVjT)\:R.n;:)::tI5iSTiYi:~ c"'wfiEilY::::i~D'::(""(5:1~.D}r.~:I~1 cih:I' ;.i1.13:['s:EW)~;':::~.:;:.::L..;--~~-_:":.~::~ .....-..-....-,......-..~:.-...-:.:....:.::-.~~..::.........::::..:.:~::::::C_~:~2~:~;I':....'..:::~:.::.i.::_L~;:.~...::.:~~\~.,?::..:-;~..2:=~.::..:;.~.~::.:.:.:..:.::.:.:...::..:.~___.._. , . . !\I,:IITI8 ...__...__._....__._._..___".._.___........_._...._.._~_...____._......_..._~..._.._..._.._.__._.__..___._.._..----;'~------_..__.._._....- ^c:; ll"'lIcV'III~S~1 -..----.-...-...-....--.. - ---..--- - --..-- -..--....... _.. ....-..-.---.---.---..---..-........:--....-.---~-Zil) coc~.;"--=-=-~= ~:I'crl :\ _ .... -.-'" ------..-.....---.----.-.-........--..--.--.-.______.........._..._.___.._..___ ,,.I.G .(, _.._____..__ . --....-----...-.......-.-.'.' ...~ .---.........-.-...... .~- ..._.~... ....-...~". "-. '-" ........"..."~..... "." .~...~ ~" "-"...-. ~''''''-'''''- ..............-.-.-- - -- - ~ ._.,.,.-_._....-._-..-_.._.........--.-....-...._w_--.. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Coe.v of Death Record PLEASECOMPLETE'.FORM. AND"ENCLOSE.FEE'",' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. p: $E'.PRINT'OR TYPE Date of Death or Period to be Covered by Search December 27, 2011 Name of Deceased Charles Matthew Blacknick First Middle Last Name of Father of Deceased Charles Blacknick, Sr. First Middle Last Maiden Name of Mother of Deceased Mary Moore First Middle Last Place of Death 62 Imperial Blvd., Apt. 3015 Name of Has ita! or Street Address Purpose for Which Record is Required Social Security Number of Deceased 11901 2229 Date of Birth of Deceased February 25, 1919 Month Da Year Age at Death 92 Wappingers Falls ViI1a e. Town or C" Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? Funeral Home If attorney, name and relationship of your cli nt t Signature of Applicant Address of Applicant Date {:;-/7-1(/( NY c. .', <P.'. ........ ,. .. . . . ';'F,.. ,., . ft~"'.'" . 1,t....:..,. ~ Number of copies requested with confidentiaf cause of death _ Number of copies requested without confidential cause of death Name Address City State 'i DOH.294A (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. Nar i~f ytlLr;J First Middle Namj c; Father of Deceared /I) NOvman ..' L/(JV1cn.1I\ First Mi die Last MaidQNam~ of Mother of Deceasf) .1_. __ F!r[( 6t"l ~iddle ro r~t Place ~(;Vl+ o.,{ Waw I'v) (' ~ Name of Hos ital or Street Addr~J1, t Purpose for Which Record is Required ":::::P:tJ5A.S .:::flat ..: ~:~J;) :.\. ::;Jl' .{t;%t{@irtt:::%::W&#ifW!@::::}~;t\It'f@mmt)):f::):::):tii" .' W t~ Date of Death or Period to be Covered by Search . l'X~ast \ ~ f;6 {;() 11 . Vtl ViII Social Security Number of Deceased (jQg - ~~- 1/77:3 D~~ Birth 15-ceai~f< Age at Death ~ da ~ear ~ W7Ll)~ Count What was your relationship to the deceased? In what capacity are you acting? If attorney I name and relationship of Signature of Applicant Address of Applicant -5. Number of copies requested with confidential cause of death .... .. ..... ....:J?4eASe:PRiNm.NAME4~Ntt/.:.' ~~~~u~~\Q) _ 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 Col!)' of Death Record . .... t.: . :~:ge\!:::~:!f:!!:{!:::::::t::!:::::):\//:!::~t)ff::::!:/://\::f::)r(){:::)!::::!:t~; FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :1~~;~~~~~~;~~~j~~r:r:~~~;\;m~m~tmmrr~~tm;~~~~~rtrftt~1~~r:i;~1~~~1~~1~~~~~~M~~~tt~j1~;~tt~~~~t~~tt~rtt~I~r\rrt~tr~~ N~em~~as~ ^.~ ~ IflVf~ I IV V""'f;v L(;U)THJ V uvct:J First Middle Last N~e of F~her of Deceased ( I/-,..;r #OM( jtJ'" S ~ I ~ First Middle Last Maiden Name of Mother m Deceased /Ilu rt;;" f;occ' NO First Middle Last Place of ~ath G- / 'It- '7 a.,f fA..#!Pjll "14,. lie/if Name mHos itaI or Street Address Purpose for Which Record is Required L .~/' Date m Death or Period to be Cover~ by Search 1/ Social Security Number of Deceased () ~ -01- .P7/'3 Date m Birth m Deceased / t3 Month C, Da 17 2/ Year IA/4f'Jllwlt:per ~q/;'; Villa ,Town or Ci Age at Death /'0 j)vki~r Coon What was your relationship to the deceas~? rv/V t,v(;;. ( 0, r I/..,-.f-, r In what capacity.are you acting? a7 eA-vT If attorney, name and relationship m your client to deceased Signature m Applicant Address of Applicant ~ .LJ ~~ Date 1'2;/UJ/// !j ILl f,A./u~ tl""'j~ It- f2eu'c)K,,/( J /V,YI".o f~b ..... ........... .:.ttt~~tttt:{:~:~:~:~:::~:~:~:~:::}::::~: ............'..,....:....,......:.:.:.:.....:........................ -.:3 Number of copies requested with confid~a1 cause of death ~ Number of copies requested without confidential cause m Name Address City State Zip Code DOH-294A (6/2000) App~iication to LOGar R'egistrar I\J[\IV_~(Cml\.'.E~~AT[ DI::T'AllTIVIEJ\IT 01:: 1-ICAUII f '" CO~J1Y of DeaHl Record VII(~1 h(,'corcl" ~.ol;!c:I:ilJn 10(1 1 :.m.........',,__ O"-""'-''''hlllllJ'....."..IfMMlIIMJJ~.....__.u~MflU'l'lIl'oNlI.IM''"llJAAIlf.ll...lWlI1UtL~lllllllll.I..t...tJJ.IIIK.n.IM1IWINUl.l4llX~"'aJMMlt.l.~ --~- -...,..,----~..~ -- --. .~-~--- --- -1~~Li\~Sf:-c;C) lVIi:;-Ci~S:ErTihIVI~6.~,JDI:::UC:C::~FEE;; .__.._-._._,_._-------.._-----~-- . .:.....,.... '., ":.'," ..:: ....'.... :. '';':<:~~....-------; IeEE: :1,'10.00 IWI CopV CilI\Jo 1=1I:icolcl CHllilicaliol1. 1:11eElS8 clo not SOIle! cash 01 stamps, ----_.~..-..~~.,-._--..,,- .--..--...-..--~~----..--,-.-.....~.,'~,._.._._.~~...._._____._...._.....~_._A..___.___:~_____. -..---.----.- ..,~--- ...;.:~ ,...;.:.::..::;r:::7'.:,',::.,:',:.. =C~.~_~~~:':7~-7'~":~~\'-'-7"':-----'~:~~"7:'-'c:p 1~~EA~~;iL <j~ljNr'()il TYP:E____~~~ . . ,:':' '.. ... ....... ....:.. .....::::..: ;...--- - 1\lcllllU (lll)r:)[;~~;i~~;';'I"------'"---"--'-'--~:-."'._--.m-__._.-:D~t;' ojD~;U~'r j='oriocl to"be Coverecl by SC~E\tl~1l A~~{l'tD . WI ND1i€,IVI /~ _ 15'- I I --,_..--J_!I..::'L_"....,"~_._.__._.~~!~IIH . I_w..t . 1\lmllu DI F(ll1\~)r lYI Dr::)Ct)E1S0:d--~--..--....._-._._-.,,_.--_._--- sz;;:~ ~;;~~lrilY I\JUIllI)er of DeC8i.:lsr:'Jcl ~ V6<U5T ',_ . ~.".~.. . W~NDH~/1Y1 ~tJ.-I'-113:J.- . ._..___I_!!.,~ Mlclclll~ I.l:l~;t __ ___._"-- MiJlCl~;,;;~MIJII;f"-;O~~;;;~;I::.:~;---i);lt:~Billl~~~;;;;~d I' 2-:T All"; ~atl1 ~~~~I.:~._._____._J:!lI(lclll" 1.(:1~;1 Month Di::1Y ~~~_._--.--- 1::>1(\(;10 ut DI0C1t11 _____..n___..___.._____.____...__ ----..------ :20 t!...IJTTl1lt1 It,Ll.. RP. Wf1~lfI}661t J~~~~~~_~!J:lm;pili'1~_~:I~.~.~~~81 Aclcll'I~:>; . \lillc/y, Town 01 ~ I~l LlI. P os c!1 D I Wh I C II H 8eo I~-I-;;-R;~;~;.---.--_..--.---'--"-.---.,-~------ .--~_.---- j) VTCIle'S S COLlnty ___'__ -- VVlkll Wi1.'; YOLIII0L'\liunsllil) to Ilw clL:!cC'i:isE:c1? ___._._E1.l1.IJ.J::7UJt"..D_iJ/ e-e- T~__~--'----'~ III wllii! c(\paclly clli.? you i:IC:till~J?_~___._, StJ..'-!iZ:=-__.__,,___ ~-~ II dItOIIH,~Y, l1iJl1le i::lncl mlElIioldllp 1)1 YUI.II client II) cluc:[)aSl~cl .._-.-.-.-----.-- To-~ErrU t:~TffTt - - - ~ ---~ -~ -- ---,-. ~_.____~...h._._,~..__.___.__~~_........_..,___._..__..~_._~__......____~___~_..~.__~~_.____....~---------.--.......------~-.. ~;I\llltJlllle ul APJlII(:rl/ll_._~ t2:..~~_______ Df:.lle_J,,2-:/~-:.-:.f.j-----_.. 1\ li III c'~:;S CJ I J\pp lie 1.1111 ._~__ _.e. A._/!(f_B.l!)L SL__ w.A.~.f'.J..d..(;rE...tZ5.--ELlL( ~ IV. '1------:-.__.---.----- , -'--..~ - ~- ....----. ,-.-. .-~-- ----- - -~ .- - -~----- _ -.---- -~----~-~- - -- ,-_.------~- .--.--.- ...--~--- ~_.....-------.-"""""-"- .. -- ~ -.---------------- -~.--.------_ _"."ri ____.._____ ri ~ri__ __ri__~__.._______---..-~-...-------..---~ :. . C ClIVI'I:)I. C'I.'.I:: 1="(") j-' 1'\1."'/\"1"1 IC'.'("I.("1""[.) j:J:I"I'N'("":A' '.C' .O'F" .j.A.N.'..LJ..A:I:J.'.y...,(.... :'1'9B8 :,." . ..........:..:,..: '.. ..----" .._-'-~._-----_..__..~~..:....-.-~-~~=--.~_._~..::~~....~~::~~~_:~~.~~~~:.....:.~~:..~~:-.::_=_:~~:~~~.:.:..~~~:2.:._~_:.1~~~~.:......--_......-- ./9.. '--'--~'--~',--,-,,--- --~--'- ,. ~.._--_.~..".~-...- -_.__......~....._~....".- -....._.___ ~._..n"....~...... '__"_,__~_.._.....__,..,_.. _,...". ~.--' _ F _ -----....... - ~----- -_..__..--........-.-~.~._.-...--.__._-~.-.-- .......--.....- NEW YOIiK STATE DEPARTMENT OF HEALTH Vital Records Section ,. . ...:....::.......;::..;.::::::.....::..PL..e..A...s'e"C'O"M"p'L'ETe' :&!!OR '. 0"(; C" "~Fi' ............................. ..."........... '.. .... ..... '., .. '.' ..' .'. 'r' MAN '.' .N. lOSe... .E.E, ..::..;.:..;:,,:..~.;.:...:;:;,;,.:.:.,:;..:::::. ..........,...;;.;..;..........,:.,;:....'_... ....... ::.,:;., . .... ..... '.' ..... ..:,.... ....:.:,..:.......... '.;. ., '''. ':.:..' .....;...: Application to Local Registrar for CO(!..Y of Death Record . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. . ',. ,.. ~... . "'- .. .... ." .,.......... ... :'::;::::;::;,'::'PLEASEPRINr OR Date of Death or Period to be Covered by Search tia,ien Last Name 01 Deceased ~r~ \'\1. Middle 1\- 2-9-1\ Name 01 Falllel ot Deceased ~r~ Fllst Middle i-\o.rtc.vl Last Social SeCLlrlty Number of Deceased '01- - 2<0 - Z-'ic.; ~ Maiden Name of Mother of Deceased A 'f\ y\C1\. First Middle Wnli1' Last Date of Birth of Deceased , , - Of - ~~ Month Da Year Age at Death T8 ~ Place 01 Death Zo \b.\\ ~ Name 01 Has)i - I 0 Street Address Purpose for WhIch Record is Required . ~~L\-k Count A-~~i~ What was your relallonship 10 the deceased? .Fi^ he. ~\ D\'r-e.c..-\tn.. In whelcepaclly are you acting? Of'\ b... h:o.l+' c~ -G."",,' ~ If aflolney. name an:-hhiP 01 your clienl to deceased Sigmllul. 01 Appllcanl ~.>~ Date 1\-:=0- II 'i:, Address ot Applicant 1=0 ~ lot J ,^,e>-~-e\@::. ~\\~ ~y jl :. .~~~~~~~m~I~;~lr1~~;~~;t:fii1~~\1i@i~~mf~~:!f~i{i:i:t)~j(!){ff.i:::~if};.: -- Number 01 copies requested with confidential cause of death ---- Number of copies requested without confidential cause of deatll ... "''':{::::';Fr::::,':p;,.eAS.t1:PRIN:t:NAMI;'\AN't)\<<OO'ft'E$$:WHERE'RSCQR ~~~~U~~\Q) Name _____ Address_____ City __.___. State Zip Code John J. Fallon Gregory McAdam McAdam & Fallon, P.C. Timothy S. McAdam Attorneys At Law November 18, ~11 ., Wappingers Falls Town Clerk 20 Middlebush Road Wappingers Falls, N.Y. 12590 ~~fG~U~~[QJ NOVf'21 2011 I TO~~~ WAPPINGER - CLERK ~ RE: Estate of Edda Eller File # 2011-174 D.O.D. 10/06/2010 Dear SirIMadam: Please be advised I am the Attorney representing the Estate of Edda Eller. In order to move forward with Estate proceedings we find it necessary to obtain (4) Certified Death Certificates. In reference to the above, enclosed please find check # 18466 in the amount of $40.00. Thank you for your usual cooperation and courtesies. TSM/kc enc: 90 Scofield Street. P.O. Box 500 . Walden, New York 12586 Tel. (845) 778-7588 . Fax (845) 778-2501 · E-mail: mfpc@frontiemet.net 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 K. Sonntag November 22, 2011 First Middle Last Name of Father of Deceased Social Security Number of Deceased John Nally 195-30-6091 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Francis Barbour 3 30 1939 72 First Middle Last Month Day Year Place of Death , Wappingers Falls 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 of the 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 November 27, 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 REC DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Reg istrar for Coey of Death Record ........ }):t:I=:t:=t=::/::=:=:::r::,:rlf,,(::,=,=::=:,:::jtPtl5* . :,,_===:=:t::=tt==ttl==)ttttt::mttttt :.;.:-:.:.:.',:-:.;.:.:-:-:',' :.:.:.:.:-:.:.:-:~ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased l.J'\w~.uce c. We~~v First Middle Last Name of Father of Deceased U4~teNc.'f' f". UJet'pLf First Middle Last Maiden Name of Mother of Deceased ~t~eth~ K~~S A~ M~~ ~ Place of Death r." \ 11)' ,... b t.. €~SC ""f.."''C d~\,,~ Name of Hos itaI or Street Address Purpose for Which Record is Required ~~wil E'sY IrflNSC.'. ~J b~('~^f f) rorA What was your relationship to the deceased? ~ ,^.v~i''' "-t ,t"~ W In what capacity are you acting? t'-4 wei"A"'- D\l'M.r If attorney, name and elati ship of yo ient t deceased Date of Death or Period to be Covered by Search t 1-1( ..1....0 L \ Social Security Number of Deceased oq~..~O" ?9~tJ. Da~ 3Birth O~Deqeased J 9' I Month Da Year . OJA~'^'9~r I i'~n or Age at Death 60 bu.lc~es' Coon MeNt c,tlei"tNCf Number of copies requested with confidential cause of death _ Number 6f copies requested without confidential cause of death Address City State DOH.294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . Application to Local Reg istrar for Coey of Death Record . ... :r.: . :~~P.Elrt??n~(~:;::~~m'f:~mm?rm~~~::::t(tm//.~t(:~/::t:n(:~~:. .... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ~~t~~~~\~~~~??r'~?\;~';:~'/~@?m:~\~f:~:'~'~~~~{'Jrt:rk::;;i/'f1'r:::~"f:'::r:t@~'jtttHltmlt~iP .'. '... . Name of Deceased 3Cro(Y\'C 3. First Middle Name 9ftather of Deceased it/b,/tO First Middle Maide~ Name of Mother of Deceased /iq u fir Co. I') ,'t(1 S9 . F1'rst Middle ~ Place of Death clal,...:f al vJ7>p/~Cj~~S Name of Has itaI.o;S'tre9{ Address Purpose for Which Record is Required a b~Aa.lr (Jf fdfJll//'1 N ,.c.o 10-- +c.... Last Date of Death or Period to be Covered by Search Jf.sf, Social Security Number of Deceased Mcda. fo Last Age at Death /'119 Year 9/ I'/Ufcitc" 55 /'Coun Signature of Applicant Address of Applicant What was your relationship to the deceased? - In what capacity are you acting? Jill/Nu. / IIofY/C ///In.; If attorney, name and relati nship' f your client to deceased I? - 1.5'1 ~ Date /1 L ;; / I ~v'(r P!rJ./rl5r Ny 125Z 7 .::.:.......:......;....... .........0"'... t...~. ~(' \ 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 CollY of Death Record -PLEASe> , _ .u:rE'FOR..ANQ'ENCLOSEFEE. ' > . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Donald A. Valk First Middle Last Name of Father of Deceased Calvin Valk First Middle last Maiden Name of Mother of Deceased Ella Wo I Ve,V'\ First Middle last Place of Death Elant At Wappingers Name of Has' or Street Address Purpose for Which Record is Required November 7,2011 Social Security Number of Deceased 104 26 8649 Date of Birth of Deceased September 3,1931 Month Da Year Age at Death 80 Wappinger Vii 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 relationship of your i(,lnt to deceased Date--1J /1 'I( NY Signature of Applicant Address of Applicant '''"''~';A'C \ ~ Number of copies requested with confidential cause 01 death _ Number of copies requested without confidential cause of death .... vL....:.; : ":'.':::'::'::: Zip Co TOWN OF WAPPINGER TOWN CLERK Name Address City 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. Name of Deceased Mauro First Middle Name of Father of Deceased Alfred First Middle Maiden Name of Mother of Deceased Lucy First Middle Place of Death 14 Fieldstone Blvd, Wappinger Falls 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 Netti November 2, 2011 Last Social Security Number of Deceased Netti 071-32-3256 Last Cannone Last Date of Birth of Deceased 11 23 Month Da 1940 Year Age at Death 70 Wappinger Villa e, Town or Cit Dutchess Count What was your relationship to the deceased? Wife In what capacity are you acting? If attorney, name and relationshil2 Signature of Applicant Date November 3, 2011 Address of Applicant COMPLETE FOR DEATHS OCCURING AS OF JAN ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death NOV 0 3 2011 TOWN Of WAPPINGER PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT Name Joann Netti Address 14 Fieldstone Blvd City Wappin2ers Falls State NY Zip Code 12590 DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for CoeY of Death Record PLEASe' . ,LEl'E-FORIUUC): . LOSE fEE' " ." FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ,PRINT :011 1'IYP& Date 01 Death or Period to be Covered by Search October 30, 2011 Social Security Number of Deceased Name of Deceased Rosario Guigliano First Middle Name 01 Father of Deceased Michael Giugliano First Middle Maiden Name of Mother of Deceased Lucy Sorrentino First Middle Place of Death 46 Martin Drive Name of Has 'tal or Street Address Purpose for Which Record is Required Last Last 132 20 9209 Date of Birth of Deceased April 4, 1928 Month Da Year Age at Death 83 last Wappinger Villa e, Town or C' Dutchess Coun What was your relationship to the deceased? In what capacity are you acting? Funeral Home If attorney, name and relationship of your clie t to deceased Signature of Applicant e-lf~ Address of Applicant 895 Route 82 Date /D PI/! ( NY Hopewell Junction '. ':F: , "8':0':: ,. vi 18l&::,;, ,,',:',':,,'; ~ 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 OEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for COe.>' of Death Record pi ,LErE 'FORM. ANQ'ENCLOSE< FEE , -'. -. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Jean M. Balducci First Middle Name of Father of Deceased William Lang First Middle Maiden Name of Mother of Deceased Gladys Palmer First Middle Place of Death 66 Pye Lane Name of Has ital or Street Address Purpose for Which Record is Required Last PRINT OR1 Date of Death or Period to be Covered by Search October 21, 2011 Social Security Number of Deceased Name of Deceased Last 115 24 2811 Date of Birth of Deceased January 4, 1932 Month Da Year Age at Death 79 Last Wappinger Villa . Town or Ci Dutchess Coon What was your relationship to the deceased? In what capacity are you acting? FUNERAL HOME If attorney. name and relations ip of your cliEtnt to deceased ~f: ~ Number of copies requested with confidential caUSe of death Date J 01 J!--4!' ( NY Signature of Applicant Address of Applicant 1 to*,: _ Number of copies requested without confidential cause of death State Name Address City 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: S 10.00 per copy or No Record Certification. Please do not send cash or stamps. Ncyn/of Deceased f\A lJ.Sh"( l~ First Middle Name of Father of Deceased &A~ k First Middle Last M'1i~n Name of Mother of Deceased De ,. 1\.~ Sq,' First Middle Last Place of Death l' ~, she.rwcoal 1~\Akr Name of Hospital or Street Address Purpose for Which Record is Required "'dAtA PLEASE PRINT OR TYPE Date of Death or Period to be Covered by Search Last Cx2t .a ~ :;J..O I Social Security Number of Deceased \"t'\eJ;\tA Date of Birth of Deceased I 0 2.Y L/7 Month Da Year W~~evs \ ~Y , Villa e, Town or Cit Age at Death ~3 L:&~ County .If attorney. name and r Signature of Applicant Address of Applicant $71 COMPLETE FOR DEATHS OCCURRING AS OF JANUARY 1 1988 lb. Number of copies requested with confidential c S8 o~(C~~~~[Q) _ Number of copies requested without confidentia cause of death ocr PLEASE PRINT NAME AND ADO Name Address City State Zip Code 4. / DOH-294A (6/2000) 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. . .:;:;,.:' ::. .~. . ,': ~~1if~~j~f~r:f~~l~;~;~~mmfm~j~j~~~m;~;l~~~j;ri~ffttm~~~~~f@1~~~m~i~r1iw~r1~1~~~~~@jtt~~(g1~~;rm~J~:~j~jjj~~~:~~~m~~1~~ Name of Deceased -\ ~eJ1~ e.. \\ Q.~e?i First Middle Name of Father of Deceased f('~<0(eS '\<,. First Middle Maiden Name of Mother of Deceased Social Security Number of Deceased ~A"" Last First Middle Last Place of Death S(jv\~e0 D\j-\~s'<; ~\)('& \~ no~c.. Name of Hos ita! or Street Address Purpose for Which Record is Required Date of Birth of Deceased \ d 9- ft).h Month Da Year Age at Death -7L ~S~ Coon , :J e\'Vc.\) ~, What was your relationship to the deceased? ~~ I' In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant (? V ~ Address of Applicant -L- Number of copies requested with confid~tial cause of death _ Number of copies requested without confidential cause of des Name ~ '\)O\l\,e V, God\~ Address ~~~~ ""~\ '\'N\\\\') ~A. City \.()~~~ YA\\ ~ State~ ZipCode IdWU DOH-294A (6/2000) i " % 'U SEGEL. GOLDMAN, MAzZOTTA & SIEGEL, P .C. Attorneys and Counselors at Law 9 WASHINGTON SQUARE ALBANY, NEW YORK 12205 TELEPHONE: (518) 452-0941 FAX: (518)452-0417 Erika C. Browne ebrowne@,sf!malbanv.com October 7, 2011 Town Clerk Town ofWappingers Falls 20 Middlebush Road Wappingers Falls, New York 12590 Re: Steven B. Ross, D.D.S., deceased Dear Sir/Madam: Please forward to the undersigned, one copy of a death certificate for Dr. Ross. His information is as follows: Date of Birth: May 7, 1940 Date of Death: November 14,2010 Last known address: 54 Top 0 Hill Road Wappingers Falls, New York 12590 Social Security No.: 111-30-1335 Enclosed is our check in the amount of $10 for the fee, and a self-addressed, stamped envelope for the return of the certificate. Should you have any questions, please contact my assistant Nancy Smith. Thank yuu. Very truly yours, SEGEL, GOLDMAN, MAZZOTTA & SIEGEL, P.e. .- Q//~. ~'-/7.(YUfAf h Erika C. Browne ~~cc~~'W~{D) ECB/nas Enclosure oelll 2011 .... i' TOWN OF WAPPING~ TOWN CLER~ M:\5635\16141\Corres\ecb 005 town clerk WF Itr.doc NEW YOFlK STATE DEPARTMENT OF HEALTH Vital R(~eold$ Section Application to Local Registrar for Cae)' of Death Record , '. "":" :':::'::>PLEA.SE COMPl.ETE' FORM ANO 'eNCJ,:;OSE:FEE':':':::~"::'::,y':::::';;:::;:;::", ,," .... ":::,,;.,,,::' ':":. ,'. .-.... . .:', ';;;. ,; FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. '.:. . ,"~..' '. '.~ .",' :. :-.: . p,t:eASE'PRINT OR Date of Death or Period to be Covered by Search Name 01 Decoased ~,~ ~ F 1J:.1 iddl Name 01 Fathel of Deceased ~~Middle ~~r Maiden Name of Mother of Deceased ~ krc::\'2-\tr Fllsl Middle Last ~\~-~e. U Last '''-9-\\ Social SeclIllty Number of Deceased 1l''O - Yo - 8S12 Date of Birth of Deceased Age at Death 1- -2..5 . \9SS- Sb Month Da Year Place 01 Dealh Cs,ac 1?,n,..- -C> q~ Name 01 Hos lilal or Street Address Purpose lor Which Record is Required . evJ.~ t)~~ Count L;~ A--\\t.\\b Wtlal W;j$ your relationship to the deceased? -f=tA~ ~I-r o~ <::::v\ D re.c~:\tn. ~m~ SignalUl e of Applicant .' Addl8$~; of Apl)hcant ~'1 \O-l\-\\ I:: 1'1 I, ~NUlllbC"O;::::~~:~~~F~: ~::d~~,~~=::~~~:~~F' .. " --- Number of copies requested without confidential cause of de h tR1~CG~U~~~ ....':':::}:'?:.<pceAsE:PRINTwArw'ie)\N'b',"A'i:)Offf$$WHER :f;~;t:?;!;i~ft{t::~~~?it~\r~f::; Name ___._____ Addles::, CIty .______________ State Zip Code ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ... Application to Local Registrar for Coer of Death Record \::;i}}j=i:i}}::}{{:::}:{=i:i::::::itiitf}:imt){:irii!t==:{:}::==t:}}i:e~"J'.agEme.dW.M#~"Q.ilaNOgQ$~Im$Em:H}::i}}}=i:I@!Ji:}fffii}ii@}!: . .::.....::::;:;:<:;.::;.:.:.:-:.:::::.;.;.;.:.;.;:::;:::;:;:;: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ... ... ................ i/::::/i:i':::(i:(f::/:::i:fff/{i}:f;;::j:ii':}::i\ji}@ff?:::!,j:j,::::::j:jfti):=j:':::ii'{@m:eW$4.$.$=::"AI.,\Qatmo1lii}!:m)I:i:iIIttt'm::::;::}}@:i:@!f@{i?i:ii:i,}::t:it:i'}?Wfft!IIIiittt'i:I::;f\'J::::::l:::m; Name of Deceased Date of Death or Period to be Covered by Search J"i."HNF /fEsrE~ c(JU/,(,4( First Middle Last Name of Father of Deceased /I,,y,ty First Middle Maiden Name of Mother of Deceased L./~/AA/ .:5~,;ev/.S's First Middle Last Place of Death tE,,.p-A/ r e. Name of Hos ital or Street Address Purpose for Which Record is Required <j . ;l'7. /1 c!o~~",v.s Last Social Security Number of Deceased oa Z. . 12.' 3? 'i'S- Date of Birth of Deceased 08' ~ Month Da Age at Death Z-~ Year .8? W~hA/~t-;;eS ~c.s Villa e, Town or Ci I::>t;rc tnS.ss Count r--A?I1/G. $E.D,$ What was your relationship to the deceased? F..l> In what capacity are you acting? FD If attorney, name and rela' s p of your client to deceased Signature of Applicant Address of Applicant Date /0 ~~/ ',:J.- 5'" <!'J.,p' I' -L Number of copies requested without confidential cause of death Name Address City ER St t~.;"'i C::R.~ Co 'TO~ DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar Vital Records Section for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .~. Name of Deceased G ~ rge~ ~o h~ ~ I~eesS .. Date of Death or Period to be Covered by Search first Middle Last ~1 ~~- ~ ~,p ~ 7 Name of Father of Deceased -C~eo~~~ ~-e~-er ~1-e~SS Social Security Number f Deceased First Middle Last Maiden Name of Mother of Deceased M L~-~d a... ~ i I-e-esS Date of Birth of Deceased Age at Death First Middle Last Month ~ Da ~ 0 Year ~J 3 Place of Death ~ C1 ~ ~,~~ r ~ U~~I r1~~S I S ~ ,ZC'~~ -~~ l Name of Hos ital or Street Address Villa e, Town or Ci , ~ ~~ Coun -' ~ e~ Purpose for Which Record is Required What was your relationship to the deceased? ~ ~ ~~ Q GI-Q-L~~'~ ~ (~ C'(P('PQ ~P In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Appficant~~._-~f '~-- ~ ~~ - Date Address of Applicant I ~ ~ 1"1 tr1LY ,~,~1~~/~,P "S~ S, ~l/' ~ 25~C~ "' Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) ,. ~_____ ~'. :` ~; ~, . f ~r~ ~~h n k~~~ ~~~~/ ~7~ NEW YORK STATE DEPARTMENT OP HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - X30.00 I Other Districts - $70.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B. Two (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Ronald C. Mellia 060-62-9490 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 12/27/2012 06/26/1960 52 From To mm / dd / Maiden Name of Mother of Deceased: Death Certificate No.: (It known) Antoinette Occhiuto First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (If known) Joseph A. Mellia First Middle Last Place of Death: 15 Caroline Drive West Wappingers Dutchess Name of HospRal or Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death confidential cause of death copies requested 15 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, ou must submit documentation of a lawful ri ht or claim. Date signed: Signature of Applicant: Mon~h Da Y~~ FOR REQISTRAR'S USE ONLY (Photocopy ID and attach to application form) 12 28 2012 Type of ID: ~ '-~. ^ Driver License ~ `~ ,~~^~ Address of Applicant: Issuing state: ~ Calabrese Anthony J Expiration date: . F (Applicant's Name) /r,,,,~ /~ ~ O C Number: ~'L'n _ 2 .. // )) 1727 Crosb Ave ,.~. Other ID, S ecif ~ {~ ~~- ~0~ ^ p Y'~ ~' y / y G (srreaa Number: ~f,~l ~~ ~~ G Bronx New York 10461 Type: (City) (State) (Zrp) Number: Telephone No.: ( )(845)674-7417 Type: DOH-294A (O6/2005) ~. 1 NEW YORK STATE DEPARTMENT OF HEALTH l/iral RPenrris Section __ Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. - P~EA~ Name of Deceased ~1,tY ~~~ ~~1. ~C'~ First Middle Last Name of Father of Deceased 1ji~~L First Middle Last Maiden Name of Mother of Deceased first Middle Last Place of Death Name ui nos uai ui Street A ess Purpose for Which Record is Required r NT.QR TYPE ate of Death or Period to be Covered by Search ~ ~- -1 ~- -~U I ~-- Social Security Number of Deceased 1 ~- I - I ~P - ~l O~ Date of Birth of Deceased AgeQat Dgeath Month Day Year ig~ Town or City County What was your relationship to the deceased? ~~+ ~1~~ In what capacity are you acting? -~,C ~~Q C,~~-~~ - If attorney, name and relationship of yCata~cl. I10 ~~~~------ ''' Straub, Funer~il >E 1`~' (~ ° ~ ~j -- ~ Signature of Applicant , , : ~ " ~'" 4u l'.O. t3ux [ 3 [ Address of Applicant n~~;,,~*~ ~ ~~u~ N' '"CpMpLETE FtQR LIEATHS ~C.C:Ut~ihrllVCa H~ ~r .~ . ,r,~+,;r, ~ :, ;:. M .. „..;.. .......,_ . D ..~l2 Number of copies requested with confidential cause of death r 3 2012 Number of copies requested without confidential cause of death QED 1 vAPPINGER -rn~n-N CLER__,_ Name ..__ Address Gity _._ State Zip Code X01-1?9~A i~i?nnrn Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Records Section PLEASE CC1MP~ETE FORM AND ~NGLUSE FED FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE pFitN7 QR TYPE, Name of Deceased Date of Death or Period to be Covered by Search TNEIrvLA f}NlAN~A j-02tC /t/of/'" a`, e?6/;t_ First Middle Last Name of Father of Deceased Social Security Number of Deceased L55~~ A DAm .7~U DSo~/ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death .~v oo~N~ `~ ~~Lt !~o Pali rv5 First Middle Last 5 3 / / 43 ~ Month Day Year .J `f Place of Death ~~ ~ ~„~ ~~~~~~ 8LU"D• rr(GE"25 FILLS ~UTCHESS (,CI 1~' PP Name of Hospital or Street Address Village, T~v+~-or~Gtty County Purpose 'for Which Record is Required To S E~"TI~S E ST~TL What was your relationship to the deceased? ~~ra~ ~r0 Dr/ZF~Tb~ - Inwhat capacity are you acting? SFjrvr E If attorney, name and relationship of your client to deceased " ~~ ~^'~-~ ~ ~'~2L~e~-a~ Signature of Applicant /~- ~~ /2 ~ Date / Address of Applicant ~. ~ 6 MArrJ ST ~/FtPPin/(TFRS I%r9~LLS Ny _... COMPL,>=TE FQR DEATHS CGGUFiRING ,qS QF JANUARY 1 1888 ~~ Number of copies requested with confidential cause of death Number of copies requested without confidential ~~~~~"'" ~~p~ ,D ...,~n PLEASE PRINT NAME AND ADDR SS WHE SHOULD B ;SENT Name _ ~ OWN Oi Wp,PPIN Address City State Zip Code DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section _- - PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. P~.~ASE PRINT QR TYPE Name of Deceased Date of Death or Period to be Covered by Search Joan A. Comes Dec. 7, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Alfred Benjamin 057-28-9018 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~ Mary Kaminsky 9-16-1935 I 77 First Middle Last Month Da Year Place of Death 9 Anthony Dr. Wappinger Dutchess Name of Hospital or Street Address -~/tt6age, Townes-Gi#~ County Purpose for Which Record is Required To settle estate ' What was your relationship to the deceased? F'imPral d; rector Ire what capacity are you acting? see If attorney, name and relationship of your client to deceased Signature of Applicant - ~ Date 12-10-12 Address of Applicant 64 E. Main St., Wappin s Falls, N.Y. GgMP~;ETE FO)~ Dt~,ATHS OGGURRIN~G AS OF JANt1ARY 1 18$$ 4 Number of copies requested with confidential cause of death Nu ~ er of copies requested without confidential cause of death P NAME'A R ApDFtESS WHERE RECORp SH~JULD BE"`Si*NT Name Address City - State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. N ~e~f~Decea$ ~ W a hd ~ ~~1I First Middle Name of Father of Deceased ~ ~ wn~ ~ First Middle ~ ~ (~ j ~~ Date of Death or Period to be Covered by Search Last ~4 (y ~, 'a. ~ t j ~~~le~~y~:, Last Maiden Name of Mother of Decease A ~ ~ Q ~ ~ G ~a1^y First Middle Last Place of Death ,~ L1 a ~ u ~- v>1 ~ ~, ~. D h , Name of Hos ital or Street Address Purpose for Which Record is Required ~, What was your relationship to the deceased Social Security Number of Deceased Date of Birth of Deceased Age at Death D~~ lb `gam ~ Month Da Year ~4 p~, F~r'ls ,p~f'C~eSS' Village. Town or City _ County Qd In what capacity are you acting? E' If attorney, name and relationship of your client to deceased f ' ~a~os`!~~' Dates ~- Signature of Applicant Address of Applicant ~ ~,~~ ~ ~~~ ~ ~~~ ,~ .~ ~- Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DEC 1 0 2012 TOW N Name `i Address ~ ~ ' '" ' C-ry r~ ~.~0 '6e+ ~ V'' ~ -State ~'e j - g~s~~- ~js ~7~ ~ ~ ~ DOH-294A (6/2000) ~ E ~ f + ~ ~ ~ ~ ~ ~ ~ ~ g ~ g i zip code l ~ s' tl 9 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased ~A I A ~~ ~~ ~--~ ~ LS ~A~-~N N First Middle Last Name of Father of Deceased , ~~Q~-~,~ ~ ~s~~~ ~ First Middle Last Maiden Name of Mother of Deceased r/~ yea. r~ ~ ~s ~ ~ First Middle Place of Death ~,~ ~~" Name of Hos ital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered 199 i Social Security Number of Deceased /~ Date of Birth of Deceased l ~ ~5 ~ ~ oF3 Last C Month ~-~- Da l Year ~' ~P~e.~ ~~11~ 1 Age at Death ~~ ~u What was your relationship to the deceased? ~~'~'Z In what capacity are you acting? .~Q ~-~~ If attorney, name and relationship your client to deceased Signature of Applicar Address of Applicant (/`Ll.~ i/` ~ ( i V- ~~-- Date ~ ~c'~~~~ z` ...--, .. -T ~ i ~ _ Number of copies requested with coM'idential cause of death Number of copies requested without confidential cause of death Name - Address City State DEC 1 0 2012 DOH-294A (6/2000) Application to Local Registrar for Co of Death Reco TOWN OF WAPPINGER TOWN CLERK ~~ ~~ ~, ,~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEASE CQMPL,ETE FORM AND ENCL.USE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PF?tNT'OR TYPE. Name of Deceased pate of Death or Period to be Covered by Search Rosrlv~gR~ 7~o~P~~ ~~ _ a~ - , 9~ ~ First Middle Last Name of Father of Deceased Social Security Number of Deceased l=/1ANK ACiv9~SE Fi t p9 g- t~- Qi ~~- rs Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~GFi/E .S-9LTE2 ~ ~~ l 9~.5' 8'7 First Middle Last Month Day Year Place of Death ,~~ LGA/'0 A /~ G<JI~tPP/~C-E,es FgLLS ~tJTGf/ESS Name of Hos ital or Street Address Village, Tea~rr r~i y" County Purpose for Which Record is Required Tv SETT"~~ ~sTr~ r~ What was your relationship to the deceased? Fy~E/~A~L ~e,2EeTo ~-- Inwhat capacity are you acting? s~~~' If attorney, name and relationship of your client to deceased Signature of Applicant Date ~~ '~~~ ~ 2 Address of Applicant _~~ &• MAC N 5'7• /w1f3 PP ~ GEQS FHG[-S Ny /ZS~90 COMPLETE FQR'pEATH$ QCCUARIN~a AS OF JANUARY 1, 1$.$8 -~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death r-,r~ r~f~ P!*EASE PRINT NAME ANp AL1D~~,S~a ~NH v Rl7 aHOUI.D BE SIB T Name NOV 2 6 2012 Address ~ V'~1APPI City Sta e ~_~ ~ c~- _.-- ode -----_-. DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH . ra_~ e~____.J.. Q....~c.... Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~~/1~a ~ . v~,~~. ,T~ U First Middle Laster e Name of Father of Deceased Nu~ ~ ~orl~u.~ > S~ Firs Middle Maiden Name of Mother of Decease d~ o /%e ~F ~st Middle ~t .Place ofnDeath Na~e of Hod ital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search Social Security Number of Deceased r'~ 7~ -- - ~..~~ Date of Birth of Deceased l~ ~ ~ l~3 S Age at Death ~3 a~ Town or City ~ ~~~1 ess What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased S Signature of Applicant ~ Date_ !J ~=1~ Address of Applicant ~ ^~ ~ ~ ~ nr Number of copies requested with cor>f'idential cause of death Number of copies requested without confidential cause of death Name .~~~5.~~~~"~ Address 7...~ f.~ G c City ~ ~~ ~ ~+~ PP ,~ C i i ~- a ~~~a~~~ N CLERK state~~ zp code ~.n/ - DOH-294A (6/2000) WALSH, WICKS F3 SALISBURY ATTORNEYS 8 COUNSELLORS AT LAW E-MAIL: infoCa~walshfirm.com WILLIAM J. WALSH (1910-2001) DOUGLAS F. WICxS ROLAND E. BUTTS PLEPySE REPLY TO: [ X 1 POUGHKEEPSIE (~ 1 RED HOOK R. KEITH SALISBURY, OF COUNSEL CHRISTIE L. OLIVERI, PARALEGAL 7405 SOUTH BROADWAY RED HOOK, NY 12571 (845) 758-8893 (845) 876-4292 (845) 758-2003 (FAX) February 16, 2012 Attn: Vital Statistics Town of Wappingers Falls 20 Middlebush Road Wappingers Falls, NY 12590 RE: Estate of Hugo R. VonBurg, Jr. Dear Sir or Madam: 75 WASHINGTON STREET POUGHKEEPSIE, NY 12601 (845) 452-8200 (845) 471-4221 (845) 473-8812 (FAx) ~~~~~ ~ ~~ NOV p 5 Z~;Z TQ wN 0; ` ~'L~~I f~-~IN~E _-,rQ~/~c(~~~ ~ We are attorneys for the estate of Hugo R. VonBurg, Jr. who died in the Village of Wappingers Falls on June 11, 2012. We need one (1) certified copies of the death certificate for Hugo R. VonBurg, Jr. Enclosed are: 1. Our firm's check in the amount of $10.00; 2. A photocopy of the death certificate for your reference; and 3. A postage paid envelope for your convenience. Please contact me at our Poughkeepsie office if you have any questions and/or require any additional information to complete this request. Thank you. Sincerely yours, Walsh, Wicks & Salisbury /~~ ~~~~ R. Keith Salisbury Enclosures 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. if $:+r''J>iRv i.~i'1.::>.L'ri:!` v44u~'~~~^ r~l i:iit{ ¢i;{ :'::i'v:`viii;:^:Yi>i:?.'.j~i:: ~::.....Y.n.:.:.v Y:... is 2n .: ..... .r .. ... r.. .. .. :./::+/.:i:,+.~~`' ~rf.1'iss5li.:YGV^:ti{:'.•:i:•ii'•~',:.~/~.`~s~'•::+~>iHi. ~-.~,^~'.,%::'.'t ~ i J:•'n::'/s $i . h'::.::. n`.-:::n::ti~'iv:: ~.. Yv. .t+~C~'$j:4.:;~~:n::.tiir,'it.hh`L:;9f':F'J.~ .C,~ J.v}:~I'rii). :v,; ..::'f:..iiii:vi:Jii>i•... ~~• .~. • v ....... G'.~4%•x.... Name of Deceased ~ ~~~~m~~ ~~ Date of. Death or Period to be Covered by Search First Middle Last ~ ~ ~ ~ ~ Name of Father of Deceased ~ Social Security Number of Deceased - ~ r. First Middle Last Maiden Name of Mother of Deceased First Middle Last Place of Death r ~ ;~ ~~~\ ~~ Name of Hospital or Street Address Purpose for Which Record is Required Date of Birth Village. Town or City Age at Death What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased ~...~ u ~~,_._.--Y ~' ~i_ Date l o~~ /~ Z Signature of Applicant -~----~ Address of Applicant N `~-~ ~ / ~ ~ ~ ~ ~~°~- ~' 4 ~'` `~ °~' ~~//~ ~ ~ _ ~ Number of copies requested wdh confidential cause of death , Number of copies requested without confidential cause of death Name Addre; 11 City ~1~ ~ ~ a r-j ~-~.,/~s state .-'~/ Y Zap code [.~~~ 7 U Application to Local Registrar for Copy of Death Record DOH-294A (6/2000) MARCUS J. MOLINARO COUNTY EXECUTIVE November 28, 2012 Office of Town Clerk Town of Wappingers Falls 20 Middlebush Road Wappingers malls, ANY 12~yU RE: Name: DOB: DOD: l .~ ~~ w'""''~-•-t- COUNTY OF DUTCHESS DEPARTMENT OF MENTAL HYGIENE Christine Gaudino 3/8/1949 10/17/2012 Residing At: 24 Delaverne Av. Dear Sir or Madam: Wappingers Falls, NY 12590 KENNETH M. GLATT, PH.D. COMMISSIONER ~` ~~,., ;% i ., , a~ ~ <~~~, ~`~;~.,A,~ AFC OS ~, -J~ ~yC ~ ,f '~, z~ ~~A , " ",~~'~~~~,.~~ . f The Dutchess County Department of Mental Hygiene, in accordance with Section 45.19 of the 1~~Iental 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 B'o'a f:~r your cooperation. ~w~,~,a G m~ I ~ Richard. G. Miller, MD Medical Director 280MH RF. V 1 ]J10 ^ 230 North Road, Poughkeepsie, New York 12601 • (845) 485-9700 • Fax (845) 485-2759 82 Washington Street, 1st Floor, Suite 100, Poughkeepsie, New York 12601 • (845) 486-3680 • Fax (845) 486-3690 9 Mansion Street, Poughkeepsie, New York 12601 • (845) 486-3700 • Fax (845) 486-3727 355 Fishkill Avenue, Beacon, New York 12508 • (845) 838-4950 • Fax (845) 838-4952 www.dutchessny.gov Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .. . :. . ;. . .. ..................:.:..:: Name of Deceased u ~h~e ~uivK1Y v 2~~ i~ ~ Date of Death or Period to Nvv- i U~ a o/a be Covered by Search First Middle Last Name of Father of Deceased 11 ~ f ~ TLf Social Security Number of Deceased ~ c e ~F}LC . First Middle Last Maiden Name of Mother of Deceased ~far9~rref c(arK Date of Birth of Deceased i~ o ~ l q~ l Age at Death ~~ First Middle Last Month Da Year Place of Death ((-~o ~'h 'e - 'jj a ~~ ~ N 5 S Name of Hos ital or Street Address Villa e, Town or Ci id5J9o Coun ~ , ~~/~~ Purpose for Which Record is Requir 7 ~, ~-~ S ~~ ~ o cx r~'S' ~ What was your relationship to the deceased? Au cuff 7~R / I n what capacity are you acting? /Uc° " '~ o f ~~ ~"1 If attorney, name and relationship of your client to deceased '-- ---~'~ - - /Vd y_ d U a o/ a Date Signature of Applicant ' ~ ' 3f/~ F%~GLS NY / a ,'j0 / i~•e Address of Applicant 5~au/ L,~d ~Z Number of copies requested with confidential cause of death Number of copies requested without corfidential cause of death DOH-294A (6/2000) t J ,~,~EV~~ ~~;RI~ ST ~t ~.. - _. ~~~ 3 - --- NEW YORK STATE'DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.001 'Other Districts - ~1 Q.00 ;per certified copy ar No Record Ce~rti~icatian Identification Requirements: Application trust be submi ted with copies ofi either A or B. (Note: Copy of Passport required if request is made firam a fioreign country that requires a U.S. Passport for travel.) A. One (1) of the folilowing forms tsfivalid photo-ID: -OR- B. Two (2) ofi the >fioltowirtg showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the •'U.S. Mi9itary photo-ID last six i6) nnornths Name of Deceased: Social Security No. of Deceased; Frieda Helmold First Middle Last Date of Death or Period to be Covered by Search: (mm~ddiyyyy~ Date of Birth of Deceased: Age at Death: 11 /15/2012 01 /06/1918 94 From To mrn 1 dd f M-widen Name of Mother cif Deceased: _ . _ Death Certificate No.; tFknown,~_ ,. Annie _ Hsiao _ _.. First Middle Maiden Last Name of'Father of Deceased: Local-Registration No.: (It known) Arthur Kiesow First Middle Last Place of Death; l Diddell Road Wappinger Dutchess ..Name of 1~iosp#al or Street Address _ Vllta~e. tovc!n-or ctty GountY Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death 6 confidential cause of death copies requested 6 Purpose for which Record i5 Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If :you acre not the parent or :child of the deceraaed ar the spouse of the deceased at the ~tme of death, you must submit docum~entatlon cf a ilawfu'i ~,ght or claim, Mete Sigrxed Signature ofi Applicant: Main oa rear ~t~R~ RErl~~'3TRAR's Ll3E ti-NL11~ 't1PMato~py D .and attach to appBc~tion farm 11 15 2012 Types cif lL~; _ _. ^ Driver L° ~ Address of Applicant: Issufng tat' ; . Anthony J Calabrese Expiration e, , . N l~Alicani's Marne) _.. 0~ :'' Nurm.t~r~r; 1 b: 20 ~2 1028 Main Street dthsr ^ ~~~N 0~ WAPPINGER (Street) ~~ N rm ber; Fishkill NY 12524 Type, .(City) (5tateJ (ZiP) Nurm'bsr; Te ephone No.: ( )(845)896-6166 Type: DqH-294A (0612oQ5) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Records Section _ _ "`P~.EAS~ GQMP~:~TE FORM AND ENCLOSE FEE _ _. , FEE, $10.00 per copy or No Record Certification. Please do not send cash or stamps. `I~~.EA~~ PRINT OR TYPE .~ Name of Deceased .Date of Death or Period to be Covered by Search ~.~,~-~~ C-~.a~no ,o - ~~- ~~ Fust Middle Last Name of Father of Deceased Social Security Number of Decease d ` ~ ~~ yyX~,~ ~ . ~at~c~ c~nb ~ j~ - SZ- ' ~`'t `i -rst Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased at Death Ag e ~--I ~ (I G~ Irl ~I~1 c~- G~1~'~ C~3 ' ~ , ~°~ `t.~ `` ~~ 1f;1~ First Middle Last Month Da Year Place of Deatti Name of Hos ital or Street~c cress illage w r City Count Purpose for Wtuch Record is Required ~' ~ll ~ ~ ~ ~~~ ~ cs ~ What was your relationship to the deceased? 1 ~ ~-~- CT ~~<<~ Inwhat capacity are you acting? Ii attorney, name and rely ionship of your client to deceased `~ ~ ~~ ^ ~Z Signature of Applicant Date ' I Z~~ Address of Applic~mt '"CQMPhETE FQR DEATHS`QOCIJRRING AS i'JF JANt)ARY 1 '19t3~ Nu ber of copies requested with confidential cause of death Nurnl~er of copies requested without confidential car-se of de ~~~~~ VL-~D ~.~. ~.. ~ .. ; F?~~,45~`PRIN7~NAME ANR AI~pRESS WHERE REGORI~"5'tiOtl~t3"8~:~~N't ~.; Name __. Address City __ _ TOWN OF WAPFINGER State Zip Code DOt-I-29aaA rFi?nnrn Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section ..PCB : `~;~~: ~ ;.:i»~:::.:.~~ : :~ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Date of Death or Period to be Covered by Search _ ~-~v~RA 2RFf• /v - r9- / a. First Middle Last Name of Father of Deceased Social Security Number of Deceased G ~A'COMD G~SPERi N~ ~ rTS /p _ O gG~ ~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~ as ~9/~ 9~ First Middle Last Month Da Year Place of Death S(0 7 P2 ~ /JGL55 ~ 2GL~ GJf~P~iNG- FPS r~9LLS, .~ u7C~~ss Name of Hos ital or Street Address Villa Coun Purpose for Which Record is Required %v 5~'~~~ ES ~~iE What was your relationship to the deceased? Fun~ERr~L ~c R EcTO2 In what capacity are you acting? S A M£ If attorney, name and relationship of your client to deceased Signature of Applicant Date ~ ~ ` a r - ~'2_-_ Address of Applicant ~~' ~~ M~~ ~1 ~ ~ • /~JA /'/'/~ C X25 rig L~5 . ivy > 2 S 90 ~' Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) • Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for COpy Of Death R@COrd Vital Records Section FEE: $10.00 per copy or No Record Certrfication. Please do not send cash or stamps. :..:.:. . .:.... . .............. ::... : ,,._ Name'of Deceased ~ ~ Q ~ ~ ~ 1 ~ t U Date of Death or Period to be Covered by Search J , ~ add /;, ` ' ~~ First Middle Last i (' N me of ther of Deceased Social Security Number of Deceased ~® First Middle Last r Mai en N~~ of Mother of Deceased Date of Birth of Deceased ~~ ~ Age at Death First Middle Last Month D Year ~ o Place of D ath Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpos~for Which Record is Requiredd ~~ ~ ~I ,~ ~l I 1 ~C9.`~~S ~-a ~ ~ W.~~ ~ ~. ~ ' What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of yo client to deceased Signature of Applicant ~ _ ~ Date ~ ~ Address of Applicant ~ ~ C '~ in, (~ ~c ~ -L Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Address City DOH-294A (6/2000) State Zip Code ~~ ,, ., . ~, w ,~ G :, ~.~.,e , ., NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Co f D py o eath Record Fee: County District - $30.A0 /Other Districts - $10.00 per certified copy or No Record Certificatio n Identification Requirements: Application must be submitted with. copies of either A or B . (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel ) . A. One (1) of the following forms of valid photo-ID: .OR_ B. Two (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID fast six (6) months Name of Deceased: Social Security No, of Deceased: Rose Lutri 112-16-0445 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 10/30/2012 - 12/23/1924 87 From To mm / dd / Maiden Name of Mother of Deceased; _ Death Certificate No.: (K known) Antoinette" _ Tuccillo First Middle .. _ _ Maiden Last Name of Father of Deceased: Local Registration No.: (If known) JOB Pizzicara First Middle Lasf Place of Death: 143 All Angels Hill Road Wappinger Dutchess Name of Hospital or Street Address t/~k~ge, fown or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidentiai cause of death.) Copies requested with Copies requested without Total number of confidential cause of death confidential cause of death copies requested 10 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If ytsu are not the parent or child M the deceased or the spouse of the deceased at the a of death, you must sulsenlt daFcumentatlon et a lawful Mght or claim. Date Signed: Signatu f Applicant• Mora, o>, ,rte, ~dR REff~~TR/df~R`$ U~~ E~hILY t` ID aryd attach to appiicatiorr form} 10 31 2012 Type of lD, ^ Driver ~iC~t't~e Address of A 'ant: I sulri Anthon J. y Calabrese p~ira e; (Applicant's Name) ~ tTl~$r; ~ 3 ~ 2012 1028 Main Street ^ her`InD' ~~;~#y~p`ppINGER ~ (Street) 0 Y Y 1/ Nu ~r; ..r.•~~nIN CLERK _ v ~-~~ Fishkill NY 12524 ___.-._.... ~ v Ty _ (City) (SfateJ (ZrP) T l Number; e ephone No.: ( }(845) 896-6166 Type: NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 /Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for trove[.) A. One (1) of the following forms of valid photo-IQ: -OR. B. Twa (2) of the fallowing showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility ar telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6} months Name of Decea~Pri~ Anselm J. Avignone I 141-20-8847 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) I Date of Birth of Deceased: ~ Age at Death: 10/ 11 /2012 11 /06/ 1926 85 From To Maiden Name of Mother of Deceased: mm/dd/ Death Certificate No.: (If known) Isabella Pasqual First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (If known) Peter Avignone First Middle Last Place of Death: 290 Ketchem Town Road Fishkill Dutchess Name of Hospital or Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidentiai cause of death.) Copies requested with 12 , r Copies requested without Total number of confidential cause of death confidential cause of death copies requested 12 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or child of the deceased the the clecaased at the time of death, yoe~ rntest subrnlt docurne ation of a r tar claim, 9 9~pp Date Signed: ~ FOR i~"E;f3i; U$E OtrILY SI nature A llca Monih Da Year /~ o~ Ip art a Gcatiort fern} 10 12 2012 Type f ID•`"~~~ Cj~ ^ Dri I~ ri~ 'l2 ~" ~o O Address of Applicant: Issuing sta ~ ~ l~ Anthony J. Calabrese Expiration date: ~ Af (Applicant's Name) ,(~ N',u'mb~:r: `` 1028 Main Street ^ f?ther ID, Specify (Street) Number: Fishkill (c;tyl Telephone No.: NY 12524 Stafe) (Zip) (845) 896-6166 Type: _ N€rmber: Type: DOH-294A (06/2005) NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 /Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-I D: -OR- B. Two (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6) months Name of Deceased: Social Security Nn of flaro~cor~• Henry Semp First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Da 10/08/2012 From To Maiden Name of Mother of Deceased: Anna Hovi First Middle Maiden Last Name of Father of Deceased: 068-09-4876 of Birth of Deceased: ~ Age at 05/30/1916 mm / dd / vvvv Death: 96 No.: (If known) Local Registration No.: (If known) Gotlieb Semp First Middle Last Place of Death: 108 All Angels Hill Road Wappinger Dutchess Name of Hospdal or Street Address Village, town or city Count Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without con~dentiat cause of death.) Copies requested with ~ Copies requested without Total number of confidential cause of death 10~ confidential cause of death copies requested 10 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, you mast submit documentation of a lawful right or claim. Date signed: FOR REG%$TRAR'3 USE ONLY Signature of Applicant: Mentn Da near (Photocopy ID and attacC~ to apptcation form) 10 10 2012 Type of ID: ~,,, Driver Licens -""""~`` D o ~~~~ ~ Address of Applicant: Issuing state: Anthony J. Calabrese Expiration dot : (Applicant s Name) Number; ER 1028 Main Street ~ Qther ID, 5p oi~w~1 o N CL~RK (Street) TO Number: _.._..---~----- Fishkill NY 12524 Type: (City) (State) (Zip) Number: Telephone No.: ( )(845) 896-6166 Type: DOH-294A (06/2005) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ ~ s~ Lv-r' 2 l Date of Death or Period to be Covered by Search ~ , Fi ~~ ~3 a ~~ rst Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of f3irth of Deceased Age at Death First Middle Last Month Da Year Place of Death l `l~ ~ 1.~ /~~6.~LS ~-Il~t, ~5 - twF~~'~E°r~G.~2, b~,r-~~~ ~ ~ Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required t'J~ .S'f ~~? ~ ~buG r ~vF,~T16~11 Dr-' / Ll~S.~ ~- ! ,~._ Lf' ~ `t ) What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased ~ ~? ~ ~''~ ~~~ ~~/~~ '°Z Signature of Applicant ~ - Date ~ Address of Applicant ~~ /~,7i~~1LFiQt~.~i~ . l-/A/'/'/~~~ ~ t~S ~~ ~d S%C~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH APP~ication to Local Registrar Vital Records Section for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .:.::,,: ,. ::: ,.:. .: . . ::: Name of Deceased kA~-~~~ ~ Date of Death or Period to be Covered by Search s>~~ 68 ~2~ ~ t2 First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last b'7 ~ ~' S~ - ~~--ZQ Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death a ( 2 ~ S~ First Middle last Month Da Year S~ Place of Death ~~ c.,~~ ~ _ ~~ .~ _ w-~-~-~`~ ~u~~~ss Name of Hos ital or Street Address Villa own r Ci Coun Purpose for Which Record is Required P~~«~ ~~~sT~~~o~ What was your relationship to the deceased? ~.~ In what capacity are you acting? _ o~.~e~ ~J ~ -~« LI~IL N`(5P - w ,(~.?PU.-q~. If attorney, name and relationship of your client to deceased Signature of Appficant - ~ Datp lo~ ° ~~ Address of Applicant ~(YS~ - ru ~ ~/~~S3us~ --o ~,Sp,.P(~~,~j4~ -~~s Number of copies requested with coM'idential cause of death Number of copies requested without confidential cause of death Name _ Address City _ State Zip Code DOH-294A (612000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for- COpy Of Death R@COCCI Vital Records Section ::<:$: - - :,,.,:>:::.:..::.:::::. .::~:.::.,...:::::.~:i: €~ FEE: $10.00 per copy or No Record Cert~cation. Please do not send cash or stamps. ..3..,. ::.3 .x3'l".:v ..:::::. ::::::::::.::::::........::............ ....,:nc.. .:... :. i• :. r.. ..iv ^i:::p: .. i.:....l... .. t!n9!: .v :..~:..:::...::L;•:::: nKiiii:8: xi:.ii:•i; ~:!: ,:. vn•n•:,,;...... • .{.ia \•. w ~,Yv. {•. ::::::::::::::.v:.:: !:::: {: •v{!:::: {. v::.y::::{. vv::.F•........:.::i:•:•:•ii:•::....::.....Y ..:.......'Ji: iii •i. .. ' iiiJ;:.... ...4 :.ti •': .r ! :t::SYf::y!:•{,::tY:<::::~i'S:<:: r:i:.'!;:' : :i :, . ,... ...v::.. r,3... .J.h:ni.:..: ., tl:. whr. 'd:2.nv.v:.v+•:: .. .. :.f::::::: :v r v .. :V .f.: L.:.vf 4 .:: •:: ;.it-. :'::y: ... •. :: .:. ..: v.:. .f~.f,.i:: ii:..:.W..:!.i:.ntn.:.vn. . . ~{i:::_:j!'::.iiy:.:.i::::::.~ Name of Deceased Date of Death or Period to be Covered by Search 12 ~' 2 ~ '~ First Middle Last ~ 0 Name of Father of Deceased ~ Social Security Number of Deceased ,• ~~ First Middle Last -- Maiden Name of Mother of Deceased Date of Birth ofrDeceased Age at Death o ~ - ZS - 5~3 First Middle Last Month Da Year Place of Death r q n . a .Name of Hos ital or Street Address Villa e, Town or C' Coun Purpose for Which~iecord is Required o~1G~ ~~~STI~-~t,/~~ What was your relationship to the deceased? ° ~ ~ In what capacity are you acting? ~~~ S(~ If attorney, name and relationship of your client to deceased ~~~~/`_ t ~ li A S 9 (/~( ! Z D t can ` ignature of pp e a Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death i~:Z•y ~.ti i\'i:}::~.<~~Gy ~v: !:.:S~,i:iYi<C::':i~'.::5 $:`Jj: ~:%:<} Name Address City State Zap Code K DOH-294A (612000) NEW YORK STAI"L==_ DEPARTMENT OF HEALTH App~IC~t1Ot1 tO LOCaI RE'glSfrclr Vital Rcrords Section fior Copy of Deafih Record " PI:~AS~ CQMPI»~TE fOFiM AND ENCLOSE FED `` .. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. r^t..~H~~ r Nam of Deceased ~ rth I ~ rtrN r un T YNf* ;' ...,.. . .Date of Death ar Period to be Covered by Search ~ nh ~en t=ir;t Middle Last G- U[, Zo I~Z Name of~Fa~,th~e"r "o~f Deceased -{-~- ~~ -W r 1GtS I ' ~ Social Securit rnber of Deceased - First Middle Last ~j ~ - - ~~ Z ~~ C~ Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~Ilcn f~n~ ~L~lv~irc Fi ~rt'_ ~Z~~ i~l~~ rst Middle Last Month Da Year Place of Dealh 1~ ~rr-ci ~~~t~ ~~~~ I er Name of Has ~ilal or Stre ddress Village own a y Count Pwpose for Wfuch Record is Required n (~ ' c~`1 ~ i-1~- ~ ~~ t ~~ What was your relationship to the deceased? "~Int~`~.~I ~ t r'~L~. In what capacit~t-are ` ~ c~/1 ~~~ (--~ ©-~ ~ ~ t (, If attorney, name and relation ip of your client to deceased Signature of Applicant - ~ Date c~ 'Pfi. ZS ~2~Iy. Address of Applicant 3~ S ~ ~ Z~ __ ;.:.. :: ~~ I-EI"E FOR DEATHS QCCUFiRINO"AS fJF JAN Ai 1(1 198 . ~~:.J'"~mber of copies requested with confidential cause of death Numt:~E.r of copies requested without confidential cause of death Name __ Address City _ _ State Zip Code DOt-I-20.tA rt~i?nnrn CLEAR ~ VICTORY SIMMONS & ORTLIEB, PLLC Counselors at Law September 21, 2012 Town Clerk 20 Middlebush Road Wappinger's Falls, NY 12590 RE: The Estate of John Edward Fordham 318-2012-ET-01052 Dear Clerk: Please be aware that I represent the interests of Kathleen Fordham in relation to the estate of her deceased husband, John Fordham. John's daughter was Tammy A. Garofalo of Wappinger's Falls. As you can see from the enclosed Notice from the Probate Court, I am required to supply the Court with a certified copy of Tammy's death certificate. Enclosed please find our firm check in the amount of $10.00 representing payment of the requisite fee. If you require additional information please contact me immediately and I will provide same. Thank you for your assistance in this matter. Best Regards, /, ~~ Michael J. Ortli ,Esquire Enclosure cc: Kathleen Fordham ~- ^ T~ John Anthony Simmons, Sr. Esq. Licensed in NH ~ Michael J. Ortlieb Esq. ~ Licensed in NH and MA 886 Lafayette Road ~ Hampton, NH 03842 (T) 603-929-9100 ~ (F) 603-929-9100 help~a clearvictory.org ~www.clearvictory.org THE STATE OF NEW HAMPSHIRE 'S~EP ~ ©`2D~1~ JUDICIAL BRANCH NH CIRCUIT COURT 10th Circuit -Probate Division -Brentwood Telephone: (603) 642-7117 PO Box 789 TTY/TDD Relay: (800) 735-2964 Kingston NH 03848-0789 http://www.courts.state.nh.us September 19, 2012 MICHAEL J. ORTLIEB, ESQ SIMMONS & ORTLIEB PLLC 886 LAFAYETTE ROAD HAMPTON NH 03842 Cure Name: Estate cf John E. Fordham Case Number: 318-2012-ET-01052 Dear Attorney Ortlieb: After reviewing the documents you submitted to open the above estate, we find additional information is required. Please submit to the court a certified copy of the death certificate for Tammy A. Garofalo. Also, please submit an amended Legatees and Devisees -Estate with Will (Form NHJB-2150-P) that includes Tammy Garofalo's son, Joseph as well as any and all of her children as part of #3 on the form. Please submit these items by October 5, 2012. If you have any questions, please call the court. Thank you, Cheryll-Ann Andrews Clerk of Court C: Kathleen Fordham NHJB-2012-DFPS (07/01/2011) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section ;.. FEE: $10.00 per copy or No Record Certrfication. Please do not send cash or stamps. Name of Deceased ~ Date of Death or Period to be Covered by Search ~~~'~ /~'~ iii ~/~S' ~i~u-~~-' .~~/ 2 ~t~~ ~~ First Middle Last -~~ Name of Father of Deceased Social Security Number of Deceased y~ / V ~7~`~`~i ~ E/ ~~; siL First Middle Last Maiden Name of Mother of Dece ed 1 ~ l~~~>~ Date of Birth of Deceased Age at Death ~~~, ,~,c ~ z~ ~q~" ~~ First Middle Last Month Da Year Place of Death ~ 7-~..lti" 2I~C.b~~~~' Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpose for Which Record is Required G,~-~~ =~~/~,~/G s ~Os What was your relationship to the deceased? ~~ In what capacity are you acting? ~~~'~~~-j nt to deceas If attorney, name and relationshi of ur cl ie ~ j Signature of Applicant _ ' LL Date Address of Applicant ~'~ 1~/~a'`~g~'~' ~~~ ~~~~ ~~ ~~.~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City _ DOH-294A (6/2000) State Zip Code Y a Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section Pl.EA>gE' FORixA AHD EHCLQSf-FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Oate of Death or Period to be Covered by Search Frederic Broe9e September 11, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased Frederic 1. Broe9e First Middle Last 102-40-1703 Maiden Name of Mother of Deceased Date of t3irth of Deceased Age at Death Dorothy Graham September 11, 1947 First Middle Last Month Da Year 6S Place of Death 70S Wheeler Hill Road Wappinger Dutchess Name of Hos ' or Street Address Villa ,Town or C' Coun Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home of Fishkill, Inc. ff attorney, name and relationship of your client deceased signature of Applicant Date September 13, 2012 Address of Applicant 1089 Main Street Fishkill NY 10 -Number of copies requested with coMidential cause of death Number of copies requested without confidential cause of death Name Address ~ City DOH-2S4A (6/2000) State SAP 1 ~ Z~+p T O wN OF wAppl -?.4lNN~~R~ ER Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section „_ , P'L~#~~> .. ~ ~ ,:!»~ Ifi~:?`~L ::CIE :::: ` , . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .. ;_ Na~ ~ Deceased ~ ~ ~ Date of Death or Period to be Covered by Search n First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased A g e at Death ~ $ ~ ~ 1 First Middle Last Month Da Year L~ Place of Dg~th ~Na.~(-~ ~ fv~ 1 Z 5~~7 g f I' ~2asa r, -}-- ~-~ n~ ~~. ,c-Ee~l`,e-~S ~ Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpose for Which Record is Required NyS(~ What was your relationship to the deceased? ~~~ ~ g~ ~ n~b~~ ~ "~^ In what capacity are you acting? ~~ ~~W~ a-.~-~ If attorney, name and relationship of your client to deceased " "~" ~\~~ ~ Q ~ °Z ~ ~- ^-~ Signature of Applicant Date Address of Applicant ~ ~ ~ Z J Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Addre; City ~ZJ an~~ state DOH-294A (6/2000) SEp 12 20tZ W N ~~ w APPINGER To TAW N CLERK ___----- Code ~ ~ S-j~~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Sertion for Co of Death Record ``?PI,~gS~ GQMPL.~TE FORM AND ~NGL~OSfr FEE' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. P<w~A~E RRINT aR TYPE _ _ ,, Name of eceased ~~ .Date of Death or Period to be Covered by Search Fi Mi d ~=~'~ • ~ ~ Ze' 1Z rs d le Last ~ Name o Father of Deceased i Social Security Number of Deceased Fi st Middle Last ~ ~'Z d ~ 1 Maiden Name of Mother of Deceased ~ t ~ Date of Birth of Deceased , G Age at Death ~ ~ 1 Y ~ ~ Z F Middle La st Montl Da e Place o~ path __{-. V E3~~11 ~--~t{r~e--- Name of Hos ~it~~l or Street Address Village own ity Count Purpose for Which Record is Required ~~ ~~ ~~ 1~~ i ~'t'~--• What was your relationship to the deceased? ~~~~ ~ ~`~t ^ In what capacity are you acting? t'- ~ If attorney, name an r ~ ship of your client to deceased Signature of Alplicant Date ~ ~ ~ ~Z Address of Applicant 3 ~ 'COMPLETE FOR DEATHS pCGURRING AS OF ~IANUAR' 1 198& umber of copies requested with confidential cause of death __~_. Numl_rF.r of copies requested without confidential cause of death ~~,~ P~:EASE PRINT IVi4M~ ANR'A[7AFtESS WH~R~` RIwGO Name _______ TOWN CLERK Address __._._____..__~ City _ __ ._ _____ - State Zip Code DOI-1-294A (F/~QOQ) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section .. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased (~ Date of Death or Period to be Covered by Search Ls~ErzA,J `1~c-AZT c~AT ~g(ill t2~ First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased First Middle Last Date of Birth of Deceased Month Year Age at Death Place of Death ~ 2 .~c,.s~«l l-ri I~~w4~-~ ~wc N Name of Hospital or Street Address Village, Town o~ity_ _ Coun Purpose for WhichpRecord is Required ©l.~Cv~ ~l ~sTt.4l~Zl~ What was your relationship to the deceased? ~~E In what capacity are you acting? P~L~c ~ ~~s'R~A'r~e~sJ If attorney, name and relationship of your client to deceased Signature of Applicant =~"~ ..~~~~~ Date $~ZQ_I t2 Address of Applicant f`~{ Sra~ ,Qa ~~~ ,mil u~o~~c~s as---(Z~ (. ~ ~p ~ -.t~~s ~a.~ s - Number of copies requested with confidential cause of death 7i Number of copies requested without confidential cause of death DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased Date of Death or Period to be Covered by Search i.~ , ~ , ~e.w L. -J~ 1 ~ t~ First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Da Year Place of Death Name of Hosaital or Street Address Village, Town or City Coun Purpose for Which Record is Required 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 Date Address of Applicant ~- ~~e~-~- ~~~ ~ ~S ~- Number of copies requested with confidential cause of death Number of copies requested without confiderrtial cause of death DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar Vaal Records section for Copy of Death Record - _ - ___ _ R( ~A~~ coMf~!*FTF FARM AN[~ ~-JC~t7SE F~{~ FEE: :G10.00 per copy or No Record Certification. Please do not send cash or sumps. --- - -- ___ PL,~AS~ P'f~1NT QR TYPE - - - -- Name of D-r.ceased ~ Date of Death or Period to be Covered by Search ~Llf P ~ ~ .A Ai PO~lT4 First Middle Last Name of Father of Deceased (J N I~ n1 o W i'J First Middle Last Maiden Name o f Mother of Deceased U+yr~~ou)nl First Middle Last Place of Death /5 ./fit LA /ER~rN~ /-~ /t . Nar1~c~ of Hospital or Street Address Purpose for Which Record is I~equired E~~ci2 Z7Av(>H7L2 Na / ~, i g~ y Sociai Security Number of Deceased 0 STS- ~a - ~3ss Date of Birth of Deceased Age at Death Month Day Year Village, /1/c Elks /r f=~ iZ r~ T Tc,r:'~/c y What was your relationship i:o the deceased? i= U+v ~ 2A~L ,D/R~c~az~_ . __ In what capacity are you acting? _-- 5~~~ If ~ttonrey, name arrd relationship of your client to deceased Signature of Applicant _ ~^..= Address of Applicant _~~_t'. /10~ DOH-.?94A (6/2000) -Dc/Tci-f rSs Countv Date ~_~~ "~a' llv -. Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEASE COMPt.ETE FORM'AND E,NCLC7SE FE, FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. AI~.~.ASE PR~INT~OR TYPR Name of Deceased Date of Death or Period to be Covered by Search cU2A8r"7'y C'. Morgn/ First Middle Last ~~~'' 3v' ~~~ 2 Name of Father of Deceased Social Security Number of Deceased l,~'~LLIAM /1'I UCC I ~ ~ 7~~8." 'I7~3 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death M~9/' I A .~~ CT~ANt~eM~'N! .~7rC'. 7, / 93~. 79 First Middle Last Month Da Year Place of Death 1 ~ I~IL~.S/;hE ~Vc (.~1flf'/°0//(sE/~S `r7LLS Dil; CyG,jS' Name of Hospital or Street Address Village, Tew~-a~•£-ity County Purpose for Which Record is Required ~~' ~ET7L~ ESTiaTL: What was your relationship to the deceased? /=cJNrPAG Di/~L TD~-- Inwhat capacity are you acting? 5 ~9nat If attorney, name and relationship of your client to deceased Signature of Applicant ~• Date ~"-'~' ~~ Address of Applicant ~ ~ G /LlAinJ S % G~!<1 P //~; `''~ LLS ~; / 2.5'x© COMPL,~T~ FOR DEATHS OGCUF~RING A$ QF JAP~t1ARY 1, 1988 - Number of copies requested with confidential cause of death _-_ Number of copies requested without confidential cause of death [~C~C~I~OML~D PLEASE PRINT NAME AND gpDRESS''WH~RE ECORp ANT Name TOWN OF WAPPINGER Address ___ N CLERK City State Zip Code DOH-294A (6/200 Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Rernrds Serfion PI~AS~ eOMpt^~TE FORM AND ~NCN*OSE FEE . FEE: X10.00 per copy or No Record Certification. Please do not send cash or stamps. __ ,. PhEAS~~PRINT OR TYPE Narne of Deceased 1 % .Date of Death or Period to be Covered by Search . ~G-tp'1f~ inn Z~ , zo iz Fist Middle Las Na e of m F a lh er of Deroased Social Security Number of Deceased - y ~ ~ _ ~ ~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~I~ r4r-rl I~l~ct~r~ '~~., . Z5, 1°~~ ~. ~ Frrst Middle Last Month Da Year Place of Deattr I~ A ~t-~ ~- . Wad t~ ~~- -~~ Name of Hos ilal or Str et A dress Village, Tow or City Count Purpose for Wtuch Record is Required What was your relationship to the deceased? ' ~tfi~~Zn In what capacity are you acting? ~ To~NY-1 If attorney, name ari r ~ nship of your client to deceased Signature of Applicant Date ~ T Z9 - ~ ~' ;.Address oP Applicant ~ ~3 `~ N ~Z .. 'COMPt~TE FQR CIEATHS~~OCCURRING AS !JF JANUARY 1 798$ Nurnher ofropies requested with confidential cause of death _-_ Numher of copies requested without confidential cartse of death P~.~AS~'~'~iINT"'NAM~;':ANR Af~pR~$5 11VM~Fi~`Fi~GO ~&~h~T-~--w~ Name . Address City __. I-I-29~A rFr?nnrn Ull ~ V~ l~ State Zip Code- ~~ TOWN OF WAPPINGER N CLERK Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of De~eased ~~ ~ Date of Death or Period to be Covered by Search First Middle Last b ~' ~ ~ "- f L Name of Father of DecDeased u ~ i tiS h-~ r~ ~ ~~ v Social Security Number of Deceased J ' ,- ~ ~ / /~ / ~ ~ First Middle Last Maiden Name of Mother of De eased Date of Birth of Deceased Age at Death First Middle Last Month Da Year Place of Death Name of Hos ital or Street Address Villa ,Town or C' Coun Purpose for Which Record is Required ~~ What was your relationship to the deceased? ~% ~ ~ ~~~ In what capacity are you acting? If attorney, name and relationship of deceased ~ ~ ~~ Signature of Applicant ~ - Date ' YAJ '~~ ~' ~' ~~~' SU ~ ~ ~ S ~~ ~ > i~ ` i1 s ~ '~ Address of Applicant ~? Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City State AUG 1 ~ 2012 DOH-294A (6/2000) TOWN OF WAPERK ER TOWN CL _,____ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Recnrcis Sertion 'PIEAS~ GOMP~.ETE FORM AND 1~N~L„OSfr FED FEE; X10.00 per copy or No Record Certification. Please do not send cash or stamps. .. ,.. , p't"EA~~ PRINT OR TYRE. Name of Deceased .Date of Death or Period to be Covered by Search _ --~-~- rY. ~ ~in I ~ a. ~.~3~r'Y~e1,r1 ~- ~ . Zc3 t Z First Middle Last Name of Father of Deceased Social Sec~.i ri t y N~unber of Deceased ~0.YY~cY~ Q.~Z~ Z. ~ + ~, ~ ~Z '~ ~ ~+ ~~~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Da Year Place of Death Name of Hospital or Str~Address Villa. e, own o ity Count Purpose for Which Record is Required (~ What was your relationship to the deceased? ~3 I ~- ~C-G*~1~.. d1Clf fi r/ In what capacity are you acting? ~"bl,~ ~' Q -~ I I If attorney, name rely ~onship of your client to deceased Signature of Applicant Date g . ~ ~Z 'Address of Applicr-ant ~ ~ 11 ' ~-` CQMPLETE FC?R DEATHS OCCUFiRINO'AS OF JANUARY 1:,:'1'988 ' . " °' I ber of r_opies requested with confidential cause of death Numher of copies requested without confidential cause of death Name ...._____ .~ Address City ___._.__.___ State F VV, rz D011-2~a_A rF~?n~rn Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Records Section py PLEASE COMPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PRINT OR TYPE Na a of Deceased `~ f Q J /')'1 k /~ Date of Death or Perio to be Covered by Search ~ . c. l U C~~t I,S ~I / gl ~ z First Middle Last Name of Fa$her of Deceased ~~ ~ Social Security Number of Deceased First Middle Last Ma' en Name of Mother of Deceased ~~1~~ G;~~l~. Date of Birth of Deceased ra I ~ ~~~o Age at Death ~ I First Middle Last Month Da Year Place of De th ~~ ~~c.~ C~~ ~ C-fi'- N ' ~~n ~ y ~ c~.~-tee SJ ~ me of Hos ital ol Street Address Villa e ow Cit Count Purpose for Which Record is Required ~L ~!~~~ What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of your client to deceased Clark Funeral Home, Inc. Signature of Applicant ~ L ~/ L t 1 Saw Mlll Rlver Road o Address of Applicant "~ COMPLETE FOR DEATHS OCCUR AS OF JA ARY 1 1988 °' Number of copies requested with confidential caus of di ~ C, ~~ Number of copies requested without confidential caus ~ ~~ 0 ~~ ~~' 1~'1_ .0 fir' PLEASE PRINT NAME AND ADDRESS WHER SHOULD-B NT Name ome, . Address City YorktOWn He+~nis, NY t s State Zip Code DOH-294A (6/98) NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - 530.00 /Other Districts - X10.00 par certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B. Two (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Margaret V. Fincken 156-26-8700 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 08/26/2012 02/25/1920 92 From To mm / dd / Maiden Name of Mother of Deceased: Death Certificate No.: (liknown) Mary Elizabeth Btarns First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (If known) Michael Doman First Middle Last Place of Death: Name of Hospital or Street Address V~lage, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death 6 confidential cause of death copies requested 6 Purpose for which Record is Required: What is your relationship to person whose record is required? Le al Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, you must submit documentation of a lawful right or claim. Date signed: Signature of Applicant: Mo~>h De r~r FOR REGISTRAR'S USE ONLY (Photocopy ID and attach to application f rm) 08 27 2012 Type of ----" ~, ~ Driv r Lic~~Q~~D A r ss of Applicant: Issuing state: AUG 2 9 2012 ames F. Matus Expirat n date: (Applicant's Name) Numbe APPINGER 162 S. Putt Corners Rd. ^ Othe ID, sN CLERK (sneer) Number: New Paltz, NY 12561 Type: (City) (State) (Zip) Number: Telephone No.: ( )(845) 255-1212 Type: DOH-294A (06/2005) ~! Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section < ~ ~ :: P[.Ef~~.. ~: ~ Lim . "= FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased Date of Death or Period to be Covered by Search O )pt ~ ~ - ~~--~( Pal N ~^'~-' ~t Z ~ c~.t"y g First Middle Last ~ Name of Father of Deceased Social Security Number of Deceased ~p3- ~~ ~ t tgg First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~ ~ - o l - Ig2'3 Fs'g First Middle Last Month Da Year Place of Death I ~ , ` ~~o ~`~~ ~ t { ~2kE~SS ~S T ~ (~ ~PP~c 4 ~s Name of Hos ital or Street Address Villa e, Town or Ci Coun uired Purpose for Which Record is Reg n ~`t ~Ot'C'E ,"OI~.LC'E ~+`ST[E~AT ~O11 '~S~ t-(1.~. -What was your relationship to the dace j~ed? ~~ In what capacity are you acting? Yo~rc~ .l.r(~EST(4 AT'a,2- If attorney, name and relationship of your client to deceased Signature of Applicant ~~2~ (s ° ild,4 EE-~/L -2~3~~ Date ~ "2 ~' l Z Address of Applicant ~~ ~ ~ $ ~ l DO c.~vS ~~ ~ ~ kP Pal 4€~S Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City DOH-294A (6/2000) State G Vv ~o~N ~` N ~~.. 'C Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section ~.: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :.. :..:.::...::.::...:: ;. .:..:.:......:.: ::::.::.:<v.:.;::.:. . . ;: ~ :< Name of Deceased ~~C / v o Date of Death or Period to be Covered by Search First Middle Last Name of Fathe f Deceased ~lJ~'~~f - GAG v~p Social Security Number of Deceased - " lam / C~ ~ ~ ~ ~ v ~ First Middle Last ( lr~ l Maiden Name of other of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Da Year Place of Deat ~ ~1 ~ n ^ ~ Cn ,,~///' S ~ ~/~ /J , n~'/C7 , ~Q~~ Name of Hos ital or Street Address ills Town or Ci Coun Purpose for Which Record is Required ~~e-n~-/ l~~~e c ~ ~ 6 What was your relationship to the dace ed? N ~'~ ~ /Ji ~ C ~~ In what capacity are you acting? 1`/ / ~ C ~~ If attorney, name and relationship of your client to deceased Signature of Applican Address of Applicant ~ ~~ ~"-' ` ~ ~ S/ ~~ `~ Date GJC~ ~7 ~~G~ ~Q Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar fOr Covv of Death Re~nrc~ Fee: County District - $30.001 Other Districts - $10.00 per certified co or N R d C py o ecor ertification Identification Requirementsa Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B. Twa (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6} months Name of Deceased: Social Security No, of Deceased: Jahn J. Flynn 103-14-1188 First Middle Last Date of Death or Period to be Covered by Search: (mm/ddiyyyy) Date of Birth of Deceased: Age at Death: 07/08/2012 11/01/1923 88 From To mm / dd / Maiden Name of Mother of Deceased: DeatR~ Certificate No.: (tf known) Mary Jane Tainch First Middle Maialen Last Name of Father of Deceased: Local Registration No.: (It known) William Thomas Flynn First Middle Last Place of Death: 114 Carolina Drive East Wappingers Falls Dutchess Name of Hospital or Street Address V~lage, town or city County Number of Copies Requested: (For deafhs occurring as of January 1, 1988 specify with or without con~dentiai cause of death.) Copies requested with ~ Copies requested without Tatai number of confidential cause of death -~ confidential cause of death copies requested 20 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship ofi your client to person whose record is required: Funeral Director if you are not the parent or child' of the deceased ar the spouse of the deceased at the time of death, you must aGbmlt doceern•ntaitien of a lawful ri ht or claim. Gate signed: Signatur f Applicant: Ma^+h oa '"~' FOR REGi~87~kit`$ U~l~ aNLY E O a~rtd attach toaarr fosrra} ` 07 10 2012 lf ype of iC~: i7rfiver license Address of ~ ant: Issuir~g~ mate. ~..,.. Anthony J. Calabrese Exp~rsa~tiar~ date: --~~=~~~~-~~ ~ (Applicanf's Name) l~lcrt~ri>er: 1028 Main Street ^ ~ I~, ~ ~ JU{1 p:2012 (Street) dumber: Fishkill NY 12524 1~: (City) (Sfafe) (Zip) Nlt~tn ber Telephone No.: ( )(845) 896-6166 Tyrpe: VVI"I-L~~iN ~UV/LUUUJ ~~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section > ,;Pt~aAl~~:..: ~ ~ PLC<.;...: Ifs:'>~~ ~ :#~1~:<::>:::?<.; <> FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased ~~~- ~D~c Date of Death or Period to be Covered by Search ~ o w ~ _ ~ g First Middle Last _ Name of Father of Deceased `~.o h.Pn--~- ~a S ~ ~ Social Security Number of Deceased - First Middle Las Mai n Name of Mother of Deceased Date of Birth of Deceased Age at Death ~ ` First Middle Last a Year Month PI f e~ f i eat ~ T D ~ ~ CL ~J ~ 111 ~' {~ ~ ~ ~ ~ ~ ~ ~~~./ ~-c-J-~ ~ Name of Hos ital or Street Address Villa e, Town or C Coun Purpose for Which Record is Required What was your relationship to the deceased? ~-v ~ E=- Inwhat capacity are you acting? If attorney, name and relati hip of your clie t to eased ~ ~ ~ ` Y Signature of Applicant Date Address of Applicant Ir Number of copies requested with confidential cause of Number of copies requested without confidential cause of death DOH-294A (6!2000) ATT ~_ i ~'~ ~ * ~.. ;` ..-. 1-24-i®~ y~qy~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased Date of Death or Period to be Covered by Search F~ st Middle Lit it N e of Father of Deceased ~CY~_~ ~t~~l'1C~-~r~ First Middle Maiden Name of M other of Deceased ~~~`Q ~~ First Middle Social Security Number of Deceased ~C~-?L~-l~-l~l~~ Last Date of Birth of Deceased a a- a-~- r 9~ Last Manth Day Year PI ce of Death ,~r ~ ~~ Lt> i / C2~W C'G~ 3 Name of Hos ital or Street Address Purpose for Which Record is Required Application to Local Registrar for Copy of Death Record Village. Town or City Age at Death What was your relationship to the deceased? In what capacity are you acting? `~~~~Ce-e- ~ll~ ~ ~ If attorney, name and re~tiQnship of your client to deceased Signature of Applicant ~%~N~ Address of Applicant ~ L ~ J Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Address City r State DOH-294A (6/2000) C ~s ~y ~a Zip Code i \ 't n .. ,. t ~: ;,..*; ~~7 FAX To: Fax: Email: Phone: Pages Re: Date: ~__~ Urgent [~ For Review ~ Please ~ Please ~ Please Comment Reply Recycle REQUEST FOR CERTIFIED COPY OF DEATH CERTIFICATE Name of Deceased ~1 ~ Q ~' sl 2 ~l 2~S,C.,I Date of Death ~~ `~ (~2- County Number of Copies ~ Cost ~~ Date Ordered Remarks When~-Copies Are Ready: MA'/IL.TO Name ~s lL~~~ C~~1 ~ ~ 1~-~ ~.~ Address / ~f ~.~ O~ `C ~ ` l City and State '~'r ~~ jj, ~' 4';'" ~, y~ ~:~. ~G "~tr -.f '~-~ i I,. ~r From: McHoul Funeral Home, Inc. 89.5 Route 82, P.O. Box A Hopewell Junction, New York 12533 (845) 221-2000 • Fax: (845) 227-1862 www.McHo~.ilFuncralHome.com ~~~~~~CD JUL 0 3 2012 TOWN OE WAPPINGER - TOINN CLERK ~-~1~ Ordered By ^ DELIVER TO ^ HOLD FOR ^ CALL S Phone Zip ~25~y NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar for Copy of Death Recor FEE: $10.00 per copy or No Record Certification. Planes do rwt send cash or stamps. Name of Deceased ~ AIR~~ ~~~-~~~ ~_ ~ •[JJ,~ Name of Father of Deceased ~' e~~e C.e! Mlf~lll r--- d~ e5 s-Fa ~ ~ c Maiden Name of Mother of Deceased • ~y,3 t~e£ SGT ~ ~D 5 c ~ First Middle Last ~~~~~ Name of Hospdal or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search Socied Security Number of Deceased Date of Birth of Deceased ~S aj~ D ~ ~p~ K ~S Villaoe, Tow~or City AgQe at Death ~J . ~~~ What was your relationship to the decs~e~sed? ~ r ` _ In what capetaty are You acting? If adtomey, name and relationship at your client to deceased Signature of Appficen' Address of Applicant Number of copies requested with confidentied cease o0 death , Number of copies requested without oorfideMial cause c'f deedh Name Address zip Code Statie ~/n ~, DOH-294A (B/2000 ,1/ NEW YORK STATE DEPARTMENT OF HEALTH \/ital RPCArdS SeCtlOn _ Application to Local ,Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased ~~1-~e-~ P. ~I raa~-Ie~ First Middle Last Name of Father of Deceased First Middle Last Maiden Name of Mother of Deceased First Middle Last Place of Death /J a, c~~ls~~. ~y Name of Hospital or Street Address Purpose for Which Record is Required ~~-~.~e {~d I ~ tee. ~~ ~ ~S-~ What was your relationship to the deceased? ~ In what capacity are you acting? ~~W If attorney, name and relationship of your client to dec asE ~- Signature of Applicant Address of Applicant ~ ~/mss /ia- I Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City _ Date of Death or Period to be Covered by Search yy~~ ~ ~~ Za ~ Z - ~une 1 ~-f , 2.~ ~ Z Social Security Number of Deceased O ~ - ~(o - '73~~ Date of Birth of Deceased Age at Death d9 /(v ~ 5S Month Da Year VII i n e~ ra ~ ~5 M{ (~,~~C~~sS ~~ ~ ) Coun Vi lave, To nor Cit ~ Z.5 State Zip Code DOH-294A (6/2000) 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. _ P Name of Deceased r First Middle Last ,Name of Father of Deceased _ ~Iltl,7~ ~Ztcf/ rrst ~ Middle Last Maiden Name of Mother of Deceased First Middle Last Place of Ueath 13 ~~- ~~ Name of Hos ital or Street Address Purpose for Which Record is Required Qom- ~f'1 i ~~ ~~~~YS HINT OR TYRE .Date of Death or Period to be Covered by Search a~-v~ ~ 2d I ~ Social Security Number of Deceased ~~lo - y 2 - ~{ 1 lob' Date of Birth of Deceased Age at Death Month ~ Da ~ Year U~ ~ ~'~-I°C~12SS Villag ow r City Count What was your relationship to the deceased? ~1 v In what capacity are you acting? COY` ~~' ~ ~~ ~ ''t ` If attorney, name and relationship of your client to deceased Straub. C;atalan~ ~ Halvey ate ~~ " ~'~ ' ~ ~ F`~fru~r<11 t~it~rne Signature of Applicant Address of Applicant !~; Vva angers Falls, N.Y. 12590 .... _... ..:. I _. COApPLE'FE FQR DEATHS e1~t;tJFiFtIN~'AS OF JANUARY 1 1988 - -~Q- Number of copies requested with confidential cause of Number of copies requested without confidential cause de ~ ~a~~D TOW Name _. Address City - DOH-294A (6/2000) Application to Local Registrar for Copy of Death Record State Zip Code NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar VITAL RECORDS SECTION for Copy of Death Record Fee: County District - $30.00 I Other Districts - $10.00 per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B' and address:he following showing the applicant's name • Driver license • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6} months Name of Deceased: Social Security No. of Deceased: Vasuben C. Shah I 083-68-9045 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 06/03/2012 12/27/1933 78 From To mm / dd / Death Certificate No.: (If known) Maiden Name of Mother of Deceased: Samratben Shah First Middle Maiden Last Local Registration No.: (If known) Name of Father of Deceased: Mangldas Shah First Middle Last Place of Death: 28 Carmel Heights Wappiner Name of Hospital or Street ,4ddress Village, town or city Counfy Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Tota! number of confidential cause of death ~D _ confidential cause of death copies requested Purpose for which Record is Required: What is your relationship to person whose record is require n what capacity are you Funeral Director give name and relationship of your client to person whose record is required. Funeral Director If you are not the parent or child of the deceased or the spouse of the deceased at the time of death, you must submit documentation of a lawful right or claim. Date signed: FOR REGISTRAR'S USE ONLY Month Da v~r •~,,,~~... ___ _- ---n to aaplication form Signature of Applicant: ~ ~ } Address of ~p`b'ti'cant: 06 15 2012 Timothy P.17oyle (Applicants Name) 371 Hooker Ave. Poughkeepsie NY 12603 (City) (State) (Zip) Telephone No.: ( )(845) 452-0460 Type of Drip Issuing Num r: Ot Number: Type: _ Number: Type: DOH-294A (06/2005G~~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Rerorris Section ... <. . PL:~AS~ ~MPIw~TE FORM AND ~Nf~t„OSE FED FEE: X10.00 per copy or No Record Certification. Please do not send cash or stamps. F~f"EAaE P _ _ .... _ RINT OR TYPE ''. N m of Deceased Date of Death or Period to be Covered by Search ~rt ~ . C ~~~~ ~c~+rre Z ~ , Zv 1 Z Fir3-i' Middle Last Name of Father of Deceased Social Security Number of Deceased F~~ n ~ ~~~ L ~°1O - Z'-t - ~ 7~8 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~a rc o~tti~ ~~v~no~r~r -~e~e~nn~~~P, 1 1~~ ~O First Middle Last Month Da Year Place of Death ~ Name of Hos ital or Street Address Village own o City Count Purpose for Which Record is Required ~,~ o-~-- ~-, fie.. A-~ r r ~-z.~Y,-ems I Di c~c~~_ What was your relationship to the deceased? ~ ~ a ~ t ~' ~ - ` In what capacity are you acting? ~~ I If attorney, name a tionship of your client to deceased I ~ ~~_tZ J Date Signature of Al-plicant n k 3 1 v Z a li f A c n pp Address o '"COMPUTE FQR Number of copies requested with confidential cause of death Number of copies requested without confidential ca~ise of death r r ~,:wwr-~ Name __ Address City _.___ State Zip Code f~l~t-t-?9aA iE,~?nnrn Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section - PLEASE CQMPLETE FORM AND ENCLOSE FED FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PL~A~E~ PRlNT'tJR TYPP Name of Deceased Date of Death or Period to be Covere d by Search First Middle Last Name of Father of Deceased Social Security Number of Deceased tJ~~LigM ~'ALv,,Y 3~0 - ~f~ - ~35'~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ivsA~/ Vt~KCE '2 ~ r /y'33 7p First Middle Last Month Day Year Place of Death ~ ~ IL1 /~ G Si d +2ME ~C' ~ t,~1'l3 Pr~in/GC2 ~c.'! r-HESS' Name of Hospital or Street Address Vie, Town city County Purpose for Which Record is Required I`$ S E-r-rcx' Es ,ATE What was your relationship to the deceased? l uN~~E'9~C D~/zEyT~,~ In what capacity are you acting? ~,9~t If attorney, name and relationship of your client to deceased Signature of Applicant _ ~T:~ /~ ~ Date ~ ' ~~~~ L' - Address of Applicant ~f " ~iAin/ S~r• Gv"/~P~~n/~tRS FH~GL5, /t/ ;J C COMPLETE FOIE DEATHSQCCUFiFiING AS OFJANtJARY 7. 198$ _-~ ~-`~-- Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death nf~(C'n PLEASE PRINT NAME AND ADDRESS WHO CORD ~HQLJLD BE S~ T - Name ,JUN 1 R 2 Address OF wAp City ----- - State; WN ~----~ C d DOH-294A (6/2000 ~j"~~.- NEW YORK STATE DEPARTMENT OF HEALTH ..._, ,-.----.i., c....ti.,., Application to Local Registrar for Copy _of Death Reco FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased j~oJ~er ~• First Middle Name of Father of Deceased ~~n~~d ~. First Middle Maiden Name of Mother of Deceased ~nCes 13. First Middle Place of Death Chelsea ~~s . Name of Hos ital or Street Address Purpose for Which Record is Required li~ner~I Nome ~I~;n Date of Death or Period to be Covered by Search 3rad~e`( ~~,q~Z6iz- Last Social Security Number of Deceased 3rO'd~e `~ o~~ - ~ c~ - ~ 3 ~ c~ last Date of Birth of Deceased Age at Death F~.~ 11 9 ~ i c~ ~ I q s~, S5~ last Month Da Year WGPP~n,~`~r ~ladb, Town o`er _ ~,rcl~ss County What was your relationship to the deceased? In what capacity are you acting? Ors h~'1o~~ ~~ ~ami~~ h u ~~n~r~~ I~c,rne If attorney, name and relationship o~ your client tQ deceased Signature of Applicar Address of Applicant _/~ 1~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death J Name _ Address City Date ~ ~ ~~~ Z State Zip Code DOH-294A (6/2000) Application to focal Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEASE GOMPLI`TE FORM AND ENCLOSE FE FEE: $10.00 per copy or 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 Mae Roland June 19, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased William Roland 045-22-9125 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death May 30. 1927 85 Unknown First Middle Last Month Day Year Place of Death Elant at Wappingers Falls Wappingers Falls Dutchess Name of Hos ital or Street Address Village, TawPr-or-~i#~ County Purpose for Which Record is Required To settle estate What was your relationship to the deceased? Funeral director In what capacity are you acting? same If ~rttorney, name and relationship of your client to dece ased Signature of Applicant -sLt~`~ ,/ ~ 6-20-12 Date Address of Applicant 64 E. Main St., Wapping s Falls, N.Y. GOMPL.ETE FOR DEATHS OCCURRING AS OF JAPJUARY 1 19$8 2 Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death PLEASE PRINT NAME AND ADpRESS WHERE RECORp aHOUI,..D BE SENT, Name ~ - Address City _ __ State _ Zip Code DOH-294A (6/2000 NEW YORK STATE DEPARTMENT OF HEALTH ~ ~:+~~ Qonnrrlc Scetlnn Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased MUGo ~- ~(bN ,~1~lp.G J2 First Middle Last Name of Father of Deceased }-~~Gu VbN ~J2Gr 5R. First Middle Last Maiden Name of Mother of Deceased >~I-I.DA Ra~~~E First Middle Last Place of Death . 3' ~/c~O S PEG T S T Nam ~ f Hospital or Street Address Purpose for Which Record is Required Td S~TTLc ESTATE. Date of Death or Period to be Covered by Search ~ _ li - ,a Social Security Number of Deceased G 7d - 3~ - 7.90 Date of Birth of Deceased /~ ~y /93 Month Day Year W grP~n/G6~S FALLS. Age at Death 73 ~T7cJTGFf ES~j What was your relationship to the deceased? t-JN ~,2g1 ~~ /t~c.to R- Inwhat capacity are you acting? S"'A N, = If attorney, name and relationship of your client to deceased Q. Date ~ ~- ~~~~~ Signature of Applicant Address of Applicant ~ ~ ~ M A. n/ ST Lc~ APP / FE2l G,y ~L s ,/V • y ~- Number of copies requested with confidential cause of death ~~~__~~'``~ ~~~~D Number of copies requested without confidential cause of death FRK Name _ Address City - State Zip Code DOH-294A (6/200 NEW YORK STATE DEPARTMENT OF HEALTH v.+~~ oornrrlc SArtinn Application to Local ,Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased S~~h i ~~ ~~ ~ ~ G~~~t Middle Last Name of Father of Deceased First Middle Maiden Name of Mother of Deceased First Middle Place of Death ~ g ~,-.N.e. Name of Hospital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search ,6 ~ 3 ~/ Z Social Security Number of Deceased Last Date of Birth of Deceased Age at Death Last ~ Month Day Year Town or L-~G t.`/ ~~ ~cJ f C~ M ~C/~. Cou What was your relationship to the deceased? In what capacity are you acting? 1-~- = ce ~ If attorney, name and relationship of your client to deceased 1, ~.--~~!} ~ ~ -"~_ Date 6 /i ~"/~ ~ ~- Signature of Applicant -~ ~ - t Address of Applicant ~_ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name =.,,.~ ~~~,_-e, / ~~ ~=,` ~ Address l~ r~~~dl~ti~~ ~ ~ ~.~ City ~c~~iY+~P:r"~ ~1~ .tiY -State Zip Code r ~ ~~ CJ ~ °! DOH-294A (6/2000' NEW YORK STATE DEPARTMENT OF HEALTH Application to Local Registrar Vital Records Section _ _ for CiOpY Of death R@COrd '' _:,'. r~~~ ~ ~ ~ PL~'.~ . .. Ifif;: i~ ..: <itCIE±':;>::::>>:::>>::>; FEE: $10.00 per copy or No Record Certrfication. Please do not send cash or stamps. :. ..> .. ;: Name of Deceased G ~ rge, So h>1 ~ 1 ~eSS Date of Death or Period to be Covered by Search first Middle Last QJ'~ u~t-- ~ ~ ~ 7 Name of Father of Deceased eo ~~~- SS Social Security Number f Deceased First Middle Last Maiden Name of Mother of Deceased M ~>~d c.~ ~ i I-e-esS Date of Birth of Deceased Age at Death First Middle Last Month 7 Da 1 v Year 5 3 Place of Death ~~ ~ ~,n~l,- p ~ ~, 'Y7 n~~ ~~,~.5 ~~lS r~co+ `^"~`' ~ ~ZS9b ~ Name of H s ' o ital or Street Address Villa ,Town or Ci ~'~~-{'1 Coun eSS Purpose for Which Record is Required What was your relationship to the deceased? ~ ~ ~-~ ~ ~ Q.-~,2~'~t (~ (''(P('Pq ~P In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant `~--~ '~-- ~ ~-~~ Date _ Address of Applicant I © ~ 1'14r1('~Y ~ ~ ~~ S ~ ~ 2~,~~1(1 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000)