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2013Application 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. ame of Deceased ~ ~ Date of Death or Period to be Covered by Search be.~~, w~o a , / a~ 113 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 35 Age at Death ~ ~0 78 First Middle Last Month Da Year Place of Death ~ ~ r ` ~~ i ~ Y `~ r~~,~--~ SS C- ~~ ~ i ~~° Name of Hos ital or Street Address Villa own o i Coun Purpose for Which Record is Required ~~ (~' ~, ~ i "~ -- --- I, rn1 _ ., . 'C~ 1 C~e, What was your relationship to the deceased? - ~ J In what capacity are you acting? `o " D~ cal ,, ~ ~ ~ If attorney, name and relations ' of you " c ~ nt to dec ased ' , ~~ i~l~E~ ~'° ~` ~~ S N ~ ~~~ t~~. I-°Y a!1, ~ 3?T~ Signature of Applicant ~ ~ °`' ~° , v Date t~- ~ Address of Applicant l~ ~ ` Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) r ~ 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. Pk.EASE:PHtNT Oft TYPE Name of Deceased Date of Death or Period to be Covered by Search Elfriede K Ernst February 23, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Martin Cordes 103-32-5333 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Barbara Wilson First Middle Last May 18, 1940 Month Da Year 72 Place of Death 79 Edgehill Drive Name of Hos ital or Street Address Wappingers Falls Dutchess Villa e, Town or Git Coun 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 licant 895 Route 82 Address of A Date February 25, 2013 Hopewell Jct NY pp ,. , . ~. 5 t7F U 'tl 1 1888 ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City State Zip Code DOH-284A (6/2000y NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: Caunty District - $:30.00 /Other Districts - `$1x.00 iper .certified copy or No Record Gertificatan 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: Frieda Helmold 062-26-2053 First IVliddle Last Date of Death or Period to be Coveted by Search: {mm~dd~yyyy) Date of Birth of Deceased: Age at Death: 11/15/2012 01/06/1918 94 From To mm / dd f Maiden Name of Mother of Deceased: Death Certificate No.: (IfknownJ Annie Hsiao First Middle Maia'en Last Name of Father of Deceased: Local Registration No.: (If known) Arthur Kiesow First Middle Last Place of Death: 1 Diddell Road Wappinger Dutchess Name of Hospital or Street Address V~Jtage. fawn 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 Total number of confidential cause of death confidential cause of death copies requested 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 ar the spouse of the :deceased at the time of death, .you must submit documentation of a lawful right ar claim. Date Signed: F"©R REl3'ISTRAR`S USE ONLY Signature of Applicant: Moan Da veer tPhotocopy iD and attach to application form) 02 22 2013 Type of I D: ^ Driver License Address of Applicant: Issuing state:: Anthony J. Calabrese Expiration date; (Applicant's Name) NrUmber: ^ Other iD, Specify 1028 Main Street (Street) N"Umber: 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 ..................... ~,{ ......:. `;.:w ... .:........................................:....~... ........{,.,..?.: :. :.::....... .:. ~# •. ~ fir:......; :•;»:: %:%::::: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. f3 't . .......... .. Name of Deceased Date of Death or Period to be Covered by Search A`^y /~ L a ~~ First Middle Last ` Name of Father of Deceased ~ ; Social Security Number of Deceased ,~ Frst Middle Last -- • Maiden Name of Mother of Deceased of~Deceased Date of Birth .Age at Death First Middle Last Month Da Year /f/ `~ ~v-~ ~~~s S Place of Death ~,~ ~s~_ ~~ (,~,,~ ~,~~~--5 ~~~~ , Name of Hos ital or Street Address Villa ,Taws or C' Coun Purpose for Which Record is Required c What was your relationship to the deceased? ~ ~ ~ In what capacity are you acting? If attorney, name and relationship of your cl'~ent to deceased Signature of Applicant ~^~~.~~ ~ ~n=~- Date `~~~~~ '' Address of Applicant ~ ~ -S I Number of copies requested with confidential cause of death . Number of copies requested without confidential cause of death Name Z,,,.~, G.,~ ~ ~ ~ ~.Y, ; ~ ~ Address J ~ EYl ~ ~~~~~~ ~1 ~ City l.J~~ y~ f/s State ~ .Zip Code 1 a.S"S= d DOH-294A (6/2000) Ap~~lication to focal Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Recorc! Vital Records Section PLEASE CO1JtPLEl'E F4RNE AIVD'~N~CI.~$E FIFE FEE: $10,00 per copy or No Record Certification. Please do not send cash or stamps. PLII"ASE P RitY'1' QR TYPF Name~,~'~ceas d''nn ~ i /~ ~ Date of Deat ~~eriod to be Cov/er~ed by Search Middle st First `~' Name of Fath r of D eased ~ . ~c,~lae~ . Cyr ~ ~~~', ~~t Middle Last Social Security Number of Deceased ~~ .- `~ ~-~1~~ Maiden N/~me of Mother of Decease~~ ir~'t" ~ Middle ~ `L~~t" Date o~Birth of D~ecease~~~ Mo/ntvh/ V Da Year A`ge~a/'t Death Place of Dea I J' )Q ~j, L ~t~t~ !~V(~' ~~ ~' ~ti~~7 ~ l ~~ ~/~~ ~ ~ ~/l,~"G1/ 161 Name of Hos ital or Street Addre ilia e o or ~ 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 ec ased Signature of Applicant Date Address of Applicant Number of copies requested with confidential cause of death r=, ~ ~'„% ~ ~ -_~ ~_, ~, , Number of copies requested without confidential cause of death FEB 2 7 213 TCJ~n ~ ~ ,~.._ Name _ Address City _ State Zip Code DOH~254A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section -- PLEASE CO1lr~iil~LE'~"E ft~Rlfil- itti~0' ENGI.;LISE FEE ' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Pt;:~ASE:PR1iNT OR ?'y'PE Name of Deceased Date of Death or Period to be Covered by Search William L. Herbold February 14, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased William G. Herbold 119-16-9123 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Anna Meier August 22, 1924 88 First Middle Last Month Da Year Place of Death ~-1~23 ~1 ~q~ls l-E, ~ l 4 Wo~~I~q~ Dutchess Name of Hos ital or Street Address Viiia e, Town or Ci Coun Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. of your client to deceased If attorney, name and relationship // IGVl'1tiG~/ ~ February 14, 2013 D t 1,~ f /~( Signature of Applicant a~ t 895 Route 82 a li f A a e Hopewell Jct NY c n pp Address o Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City . ". ~, , State ~-- N. ,. .:lpM~.~ g ~! ~€~ 9r DOH-294A (8/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section PLEAS C~UUIdiI~LETE~Ft'1RIfiI Ai~D ENCiI~OSf FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PL1E:'ASE~:PHEN7 OR TYPE Name of Deceased Date of Death or Period to be Covered by Search Eufemia Betancourt February 12, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Juan Montanes 063-24-3l~3 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Gumercinda Bijio September 23, 1920 92 First Middle Last Month Da Year Place of Death 2 Ervin Drive Wappinger Dutchess Name of Hos ital or Street Address Vitaa e, Town or Ci Count 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 ~ t~~~1 ~ ~~ Date February 13, 2013 Signature of Applicant 895 Route 82 Hopewell Jct NY licant f A dd ress o pp A 4 -Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City _ State Application to focal Registrar for Copy of Death Record _. rnq~ .1..;.'198as..: G~5 r'~ r~ rj,;,; --,.,_~ FEg 1 4 ;~HOU'LO BE,, N: ~~`'; u ~ ~a~~~~ yTCV+~'~ .~ Zip Code DOH-294A {6/2000) NEW YORK STATE DEPARTMENT OF HEALTH .,:...~ fl..,..,.a~ co..+~.,.. 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. p1„tiASE:PHit+1'1':Qf~C TYFE Name of Deceased Date of Death or Period to be Covered by Search Anthony Edward Pagano February 2, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Anthony Pagano 129-86-6100 First Middle Last Maiden Name of Mosher of Deceased Date of Birth of Deceased Age at Death Mary Polce December 15, 1954 58 First Middle Last th Da Year M o n PI Letif D.eDaOSG ~- d e a t ~ ' AP tn9Gt~ Dutchess V `r p Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Recard is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. If attorney, name and relationshi o our client to eceased February 4, 2013 Signature of Applicant t 8 5 Rou e 82 li f A Date Hopewell Jct NY can pp Address o ;; .:, uu >.. _ .. Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death ~' ,_,,-. Name _ Address City - State Zip Code DOH-294A (6/2000) MURPHY & LAM BIAS E -- Ar[arne}'s at Law ~t~•~~1 ~~)1 •'ItI(1 Donald J. Lambiase, Esq., PLLC George A. Smith, Esq.* George Rockman, Esq. PC, Of Counsel Richard Burke, Jr., Esq., Of Counsel *Also Admitted in New Jersey February 1, 2013 Town Clerk Town of Wappingers 20 Middle Bush Road Wappingers Falls, NY 12590 Re: Louis Lucato v. Kupetz Dear Madam Clerk: 26 Scotchtown Avenue Goshen, New York 10924 (845)291-7100 Fax: (845) 291-7171 e-mail: lawyers@mllawonline.com www.mllawonline.com Frederick J. Murphy, Retired 2006 We are attorneys representing the Estate of Louis Lucato in a dental malpractice litigation. We are in need of a Certified copy of Mr. Lucato's Death Certificate. Enclosed is our firm's check for $10.00 in satisfaction of your fee. Could you please send same to us at your earliest convenience. Enc. r ~,',~ ~ i ~ ~'~. -- _ ,t FEB ~ 4 1 ~~ i' a ~ T~~~.~e ~~° k~ ~~' Very truly yours, Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section Pt.EA'SE ONiPLETE F~Rw1 AND E1~i.C~SE fEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. E:P RINT CCN~ Name of Deceased Date of Death or Period to be Covered by Search Joan Coffey December 31, 2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased John Lynch 070-32-9425 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Helen Stewart August 15,1940 First Middle Last Month Da Year 72 Place of Death 12 Ronsue Drive Wappinger Dutchess Name of Hos 'tal or Street Address Viila ,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. If attorney, name and relationship of y r client to deceased Date January 2, 2013 Signature of Applicant Address of Applicant 1089 Main Street Fishkill NY 5 ~ ~a ~.~ __, _._. _ - Number of copies requested with confidential cause of death _ Number of copies requested without confidential cause of death JAN 0 2 2013 R Name Address City State Zip Coda DOH-294A (8/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Co of Death Record Vital Records Section _ ::`PC.~ASf. CQMF~!»El'E FORM ANQ ENOI«QSE'.FEE FEE; $10.00 per copy or No Record Certification. Please do not send cash or stamps. F'~~A~~ PRINT OR fiYP~ ~'~ ;:: _ Namre of Deceased ~ ~'~`., ! ~ inc -rz L .Date of Death or Period to be Covered by Search ---t-- ~ -- 1 ~+ First M Last ~ ~ ~c~ f3 ~ ~ Name of Father of Deceased Social Security Number of Deceased ~~erl~~ ~~~e~t" Fi y cl`1 -- 3~-t ° Z-°I~ 3 rst Middle st Maiden Name of Mother of Deceased l ~ Date of Birth of Deceased ~ ` Age at Death -" am ar >~ via ~33 ~c= . Z ~ 1 First Middle Last Month Da ~ Year Place of Death ~~ ~~ ~_ N l ,~ r ~, V V ~f ~ef ~-~ ame of os ilal ar treet Address Village, own City Count Purpose for Which Record is Required What was your relationship to the deceased? ~y ~G'~.~ ~r~.L~_. In what capacity are you acting? ~(~ n -t a~~ yY1 1 If attorney, na tionship of your client to deceased Signature of Applicant • Date ~ ~ - ~ 3 -}~ Address of Applicant ~ `~ ~~~ ~~~ (~ Z Name ___ Address City ~._ State Zip Code ~o--- ?aaA r~i?nnrn NEW YORK STATE DEPARTMENT OF!HEALTH VITAL RECORDS$ECTION Application to Local Registrar for Copy of Death Record Fee: County District - $.30.00 l 'Other Districts - $1 QAO iper certified coipy ar No Record Certification Identification Requirements: Application must be submitted with copies ofi either A or B. (Note: Copy of Passport required i!f request is made from a foreign country that requires a U.S. Passport fiortravel.) A. One (1) of the following forms of valid photo-lD: -0R- B. Two (2') of the fiollowing showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or tekephone 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: Paul Zahensky 062-14-0194 First middle Last Date of Death or Period to be Covered by Search: (nt,~ddiyyyy) Date ofi Birth of Deceased: .Age at Death: -- .. _ O l /07/20 ~3 _ - ~ ~:: ~_ .~::... 06/ 16/ 1922 90 _ _._ .. from '. :.:.. .... . ~ ,.; . To mtn 1 dd r Maiden. Name..vf Mother t1f_[~c8s~st+l:__., m. _ Death Certificate No.: (~krrnwn) .._ ~ : Caroline :. .. . ~ . `. Unknown _ First _ . __ .: ~ Aiftddle Maider+ Last Name of.Father~of Deceased; Local Registration No.: (tfknown) Andrew Zahensky First 1Uddle Last Place of Death-: 52 Scribo Lane ~ Wappinger Dutchess _ Natne-pftlospftal or~sheat~dctress _ ... _ ..._ _ _ W fawn rxcity t;oErrrty Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without con~dentia! cause of death.) Copies requested with Copies 'requested without Total number of 10 confidential cause of death 10 confidential cause ofi death copies requested Purpose'for which Record. is Req"ui~red; What is your relationship to person whose record is required? Funeral Director Ln~hat capacity are you acting?.. If attorney, give name and relationship of your client to person whose record is required: ` Funeral Director. _ ,. _ -- - if :you :ere nit the parent or chi>kd df the dgoerltsed ar rthe spouse of the deceased . ~ at the time of death, ,you tnuat submit documet~ta~tion of .e hswful might or cla~lm• rsate signed: ~©R RL"O(13TRAR"3 tJSE I~NLY Signature of Applicant: Moron oa vaa~ ~!Ph~lo~py ID arut attach o appficatinn form O1 08 2013 TYpeaf la; Driver License i Address cf Applicaint: lssurt~g state: Anthony J. Calabrese Exprati4M date; (Appli'cant's Marne) _ _ .. NUM1L7B1°: _ ^ Other 1[J, 5peci'fy 1028 Main Street (Street) Number: Fishkill ~ NY 12524 Type; (City) (5fate) fZ?p) Norm ber; - -T-el~ptrone No.::: ( ) (845) .896-6166 _ Type. NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Conv of Death Record Fee: County District - $30.00 !'Other Distracts -'x`10.00 iper certified copy or No Record CerYrfiicati4n Identification Requirements: Application must be submitted with copies of either A or 6. (Note: Copy of Passport required i~f request is made from a 'foreign country Ghat requires a U.S. Passport for travel A. One (1) of the following forms of valid photo-lD: -0R- B. Two (2) of the lfollowing 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-lD last six (6) months Name of Deceased: Social Security No. of Deceased: Carol Ann Kunca 071-28-1030 First .Middle Last Date of Death or Period to be Covered by Search: (rnr»/ddryyyy) Date of Birth of Deceased: .Age at Death: O 1/08/2013 12/10/1935 77 From To mm / dd Maiden Name of Mother of Deceased: Death Certificate No.: (lfknown) Bertha Mang First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (If known) Robert Pressner First .Middle Last Place of Death; 64 Spook Hill Road Wappinger Dutchess Name of Hospital or Street Address Vdlag~e, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or wifhout contidentiai 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 aCtirt,g? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or chi d of the deceased or the spouse of the deceased at the time of death, ;you :must submit documentation of a lawful :right ar claim. Signature of Applicant: Moen ~g~oa v~~ F'C,R RE611~TRAR'3 U`SE ONLY ~ tPhotocopy tD and attach to application form) O l 10 2013 Type of I D: ~~- ^ Deriver License Address of Applicant: lss>rrin,g state:: ~ Anthony J. Calabrese Expiration dgte; (Appticant'sName) Number: JAN 1 ~ 2Q13 1028 Main Street ^ Other ID, Sp ~UWN d~ ON~F'PINGER (sre~;i N-urn bar.: TC~ W~ r` I G D ~i Fishkill NY 12524 Type: (ciryl ..(state) (zial Nurn bar: Telephone No.: { )(845) 896-6166 Type: WUY'I-LJ4H (Ub~. NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 t Other Disttricts - $10.00 per certified copy or No Record Certificatian Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is madefrom 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 (2j of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Ufility 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: Roberta Wood 161-26-4409 First Middle Last Date of Death or Period to be Covered by Search: (mmidd/yyyy) Date of Birth of Deceased: Age at Death: 01/29/2013 08/10/1934 78 From To mm / dd / Maiden Name of Mother of Deceased: Death Certificate No.: (If known) First Middle Maiden Lasi Name of Father of Deceased: Local Registration No.: (If known) First Middle Last Place of Death: 65 Flint Rock Road Wappinger Dutchess Name of HospBal 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? 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 :must submit documentation of a lawful right or claim. date signed: Signature ofcant: Month oa vear FOR REGISTRAR'S USE ONLY tPttotocopy tiD and attach to application form O1 30 2013 Type of iD: Driver License Address of Applicant: Issuing state: _ -°-- n ~ ~ ~ ~~ ~D . Anthony J. Calabrese n r Expiration ate; - -, / ---~ (Applicants Name) N'Umber: ~ Other ID, Specify ~A 1028 Main Street (Street) NUmber: ~' d' <,,„'°~~t~PIN`7ER T®~~ ~~-~~K 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 _ RL~,A,S~ COMPLETE FORM AND ~NCLOSF F~ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. - ___ __. _ PLEAa~ PR[NT QR TYPE Name of Deceased Date of Death or Period to be Covered by Search ~ ~' `~`~ ~ 3 First Middle Last Name of Father of Deceased Social Security Number of Deceased O R M L L E I-~ E t'TL ~ ~ ~7 y ~ ~ ~ _ ,3 ~ ~ First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death S RR q N ~' f.} ~J r 1~tf~ L f,- i f r D i 9.2 H ~~ First Middle Last Month Da Year Place of Death ~-{( .Do2o-rNy HEIGHTS ~AOPinIGErE' -I)ur'cHESS ~ Name of Hos ital or Street Address ~, Town o County Purpose for Which Record is Required To S ~~~E C 5 -r !i r~ What was your relationship to the deceased? ~c. ) ti Fiz A-C. ~ r 2 c: eTo r _ __ In what capacity are you acting? S A M~ If attorney, name and relationship of your client to de ceased _ Signature of Applicant ~7" Date- ~ `-~' /3 ---- Address of Applicant S ; (iU ~'~ ~ . S fi c. ~ S _ n(~ i ZS4 O_ ____ I '~-~ Number of copies requested with confidential cause of death O~ JANUARY 1, Number of copies requested without confidential cause of death (~~`/'~~ PLEASE F'FtINT NAME, AND AI~DR~SS WHI*RE RE O~tp 5HQ Name _. QWIV CyF 1N'gPPINGER ! Address ~ T®V1s~ ~~~RK City State Zip Code DOH-294A (6/2000) M ~, Frederick D. Romig Legal Assistant Attorney and Counselor a t La w Beth H. Witkowski 8 Barrister's Row, Suite 1 (Route 9 and MacFarlane Road) Wappingers Falls, New York 12590 January 15, 2013 Christine Fulton, Town Clerk Town of Wappinger 20 Middlebush Road Wappingers Falls, New York 12590 Re: TIMOTHY J. O'TOOLE, deceased Date of Death: 01/10/12 Dear Sir/Madam: Telephone (845) `197-1000 Facsimile (845) 297-1959 *AlsoMember Connecticut Bar (~ , ,~ ~ ~ ~~~1 ~~ i~ JAN 1 ~ 2013 •~ With regard to the above would you be so kind as to provide me with two (2) Certified Death Certificates for Timothy J. O'Toole who died a resident of the Town of Wappinger on January 10, 2012. Enclosed please find the following documentation: 1. Application to Local Registrar for Copy of Death Record 2. My disbursement check payable to the "Town of Wappinger" in the amount of $20.00. 3. Self-addressed prepaid envelope for your convenience Do not hesitate to contact me if you have any questions. FDR:bw Enclosures F: FILES~EST aTESDF,.aTHCERT LTR.Uk .p Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section Pt1~4f~~~. ~ Ifii?.: D~~I~ ~ t?IrE . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. "....: ., <:.::::> ~:t?' ' . ~ ,, ~1IILV'I~'.'II:"Ift~'1~>> ; . .. .; '! :; ..... .:. Name of Deceased Date of Death or Period to be Covered by Search Timothy J. O'Toole 1/10/2012 First Middle Last Name of Father of Deceased Social Security Number of Deceased James W. O'Toole 088-48-6365 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Catherine M. Steigert 10 1 1954 57 First Middle Last Month Da Year Place of Death 11 Daniel Sabia Drive Wappinger Dutchess Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required Estate Administration What was your relationship to the deceased? Client In what capacity are you acting? Attorney for Estate If attorney, name and relationship of you de Concetta M. 0' Toole, Survivin Souse Signature of Applicant Dat J ~ Address of Applicant 8 arrist is Row, Sui 1 Wa in ers Falls ? Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death 'Name Frederick D. Romig, Esq. Address 8 Barrister's Row Su; to t Cry Wappingers Falls State NY Zip Code 12590 DOH-294A (6/2000) ORBALLY ARTLAND AN LEYEA LLP CHARLES J. CORBA LLY (1966) JOHN J. GARTLAN D, JR. (2003) ALLAN E. RAPPLEYEA (2010) JON HOLDEN ADAMS MICHAEL G. GART LAND VINCENT L. DEBIASE FAUL O. SULLIVAN (aL+o FL1 WILLIAM F. BOGLE, JR. RENA MUCKENHOUPT O'CONNOR ALLAN B. RAPPLEYEA (also G7~ LEAH J. BALASSONE KAREN E. HAGSTROM WILLIAM W. FRAME KRISTEN L. CINQUE OJCounsel RICHARD V. CORBALLY Wappingers Town Hall 20 Middlebush Road Wappingers Falls, NY 12590 Re: Death Certificate Dear Madam/Sir: A HERITAGE OF LEGAL COIJN9EL Administrator CAROL ANN NEVILLE _,: _ ` __.-_-"`~ Regional 0~ices 30 FRONT STREET BA RDAVON BUILDING PO BOX 679 35 MARKET STREET MILLB ROO K, NY 12545 POUGHKEEPSI E, NY 12601-3285 845~677~5539 TEL 845-454-1110 TEL •845.454-4857 Fax s45-677-6z97 FAx E-MAIL: info~cgrlaw.com W WW.CG RLAW.COM 6369 MILL STREET PO Box 366 RHINEBEC K, NY 12572 845876-4091 TEL 845-8767192 fAx 2013 3 J BY APPOINTMENT: anuary , CLEARWATER, FL 33756 We represent Mary Lou Logan. We need a death certificate for her deceased husband, Thomas Logan. Mr. Logan died in February of 2005. Enclosed is my firm's check in the amount of $10.00 representing the fee to obtain this death certificate. Also enclosed is a stamped self-addressed envelope for your convenience. Thank you for you assistance in this matter. Very TLAND AND RAPPLEYEA, LLP Muckenhoupt O'Connor RMO:jmg Enclosures .~ 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 Cert'rfication. Please do not send cash or stamps. Name of Deceased ~ Date of Death or Period to be Covered by Search 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 l ~ ~ ld JZ q! wa ~~~ ~S r~s , Uv'Y ~ ~~~ Name of Hos ital or Street Address Vill ,Town or i ~%~n Purpose for Which Record is Required ~ ~ What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationshi your cli r'~ ' to de - r Signature of Applicant ~,,,.°-. Date ~ ~ / Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (612000) ~ _ ~ •--•^ ..'.. -rr~.-.tee..-,.~____'~ ~~ , _ RK STATF' ~~ .~ ~Aa ~ 9y1 It ~ ~ * ~ ~ @ }~~ ~~~ Application to Local Registrar NEW YORK STATL_ DEPARTMENT OF HEALTH ~Or CO of Death Record Vital Rec~rcts Section :.m.. ;: ;PI:EASI e'QMf~FETE'FOFtM AN(J ENC:~;OSE.I*EE ;: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. _ P~,~AS~ RFtINT QR TYPE Name ut Deceased .Date of Death or Period to be Covered by Search 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 ~tnh~ ~av~ lot'1 ~ 2 - Z --1~i33 ~-°~ First Middle Last Month Da Year Place of Death '/~' l^Q ~n Y~ • `~ ~~ ~-~ ~~~ t C Name of Hos i .~I or Street Address Village, own r Cit oun Purpose tar Which Record is Required n c~-F L- t ~ ~~~i _ ~ ~•-,c~ l What was your relationship to the deceased? ~~~'~~ c f~~ In what capacity aro you acting? ~.~~ ~ ~ ~ t If attorney, name an onship of your client to deceased , ~ ~ ` ^ ~ Signature of Applicant Date Address of Applicant ~ ~3 1 Q 11,~j `COMPf~ETE FQR LIEATMS QCCURRIN~ AS OF JANIJARI(1 .'t~~~ ~ urnher of ropies requested with confidential cause of death _ Number of copies requested without confidential cause of de th ' G~L~~~~,, ~ n ~ `~ ~ JA N Name _._ Address City T_ t State ,,~, ~ E ~' ~i~,~,~~G ,~.~ _~_ R Zip Code ~. Leonard Klein Counsel Arthur L. Gellert Geoghegan John A Stephen E. Ehlers . Scott L. Volkman * S. Nina Gellert Justice George D. Marlow David R. Wise MacLeod Roderick J Appellate Division (Ret.) . Kelly L. Traver* Senator Stephen M. Saland Keith G. Ingber Robert C. Vincent, Jr. Robert E. Noe Lillian S. Weigert John J. Evans Richardson' Pamela B Joseph H. Gellert . Elizabeth M. Corrado (1907-1989) *Also Admitted in CT 'Also Admitted in N1 Gellert & Klein,P.~ Attorneys at Law 75 Washington Street • Poughkeepsie, NY 12601 (845} 454-3250 (845) 454-4652 fax Westchester County Office 3010 Westchester Avenue Suite 302 Purchase, NY 10577 (914) 249-0100 (914) 249-0111 fax www.gklaw.us January 3, 2013 Town Hall 20 Middlebush Road Wappingers Falls, New York 12590 Dear Sir/Madam: Re: Estate of Thelma Amanda Force Our File No. 28509.0023 Please be advised that this office represents Gail D. Clark, Administratrix to the Estate of Thelma Amanda Force. We are currently in the process of liquidating the decedent's bank accounts and each financial institution requires a certified death certificate. Therefore, I enclose a check made payable to the Town of Wappinger in the sum of $20.00 which represents your fee for two (2) certified death certificates. The decedent, Thelma Amanda Force, died on November 26, 2012 at 72 Imperial Blvd., Apt. 1311 in the Village of Wappingers Falls. I futhCi cnciose apre-addressed stamped envelope for your convenience when returning the death certificates. Thank you for your kind attention. Very truly yours, GEL ERT & KLEIN, P.C. BY: ~f~,~ KELL L. VER KLT/alv Encl. ktraver@gklaw.us cc: Gail D. Clark, Administratrix ~`1 F:\USER\clients\F\Force, Thelma Estate\Letters\Ltr.Town HaII.Request DC.12.28.12.wpd I ~- 1 J JEJn-teotptreulnl ~~~~„", °' CiEPARTMEN'f4FHE~ILTH , ~-- AEG~~ ND ~' CERTIFICATE OF"DEATH s-rA-,~ FIDE r,uMBER RE3h]ENCE 3B HOUR E OF DEA 3 LAST 2. SEX Mo~ DAV vEAA 1. NAME: RRST ` MIDDLE rEtAAiE 'Thelma Amanda Force _- ^, ~ z 1 1 2 6 11- P m .NCNB 48. IF FACILITY, DATE ADMITTED: : 4kPLACEOFDEATH MOSPffAL HDGPfiAI: HOSRtIAL NURSING PRIVATE HOSPICE :OTHER I MONTH paY YEAR LTfY ISp FACI l: F HOME AFSI Q ^ (. ~ yCheckonel DOA ER OUTPATIEtl1 INPAi1EDf 4C 4C. NAME Of FACILITY: (ll not facility, give address) 4D. LOCALITY: (Check one andspecrryJ :. 4E. COUNTY OF DEATH: TOWN I LA G E 1 CITY' VIL ^ . / ~ ~ { ` ~ , / 'T ~ {J f~ 1 'T ~3 ~~ ^ IJ ^ W I rl Ct~S 1-A ltS ~al'fCM PS4 7'1~~ i , !i Q,` 1 Y~ d f t 4G s a eJ IF.MEDIDALRECO ONO. 4G WAS DECEDENTTRANSFEAREDFAOMANDTHEAINSTITlIF10N7(1/yesspecilyinstrtuhonnalne, orfown, ounryan ~ N~ YES (~ ~ _ [f' ^ DATE OF BIflTH: 6A AGE IN 66 IF UNDER 1 YEAR 6C. IF UNDER 1 DAY .10.. CITI AND STATE OF BIRTH (!t not USA, Country and 7B. IF AGE UNDER 1 YEAR NAME OF HOSPITAL OF I BIRTH' 5 . YEAfiS~. I ENTER:. ENTER: _t Regbr/Pmnnce) : I MOIJIH DAY YEAR I monNS. drys I Hours minutes ~ i I Bristol, TN 1938 74 ,i. ', 05 31 ~ I l ~ yrs SERVED IN.U.S. ARMED 9. DECF-ENf OF HISPANIC ORIGIN?ChxkW bmar fhafbd0esaue Meum me oernamt s. Sp+mmik l-a~. 1D DECEAENT'S RPLE:CM.:t axamore ruu la Kdi to MUr me decedean cm'aneml hknseM n'M?eitabe B . FORCES? fSpeeKYab+n}., A ~ No, not SpargsMgspenklEaeiw ' B ^ Yes, Mevctn, Mexican Artrcriran, Chicano A~ WhttelCaucagan B ^ 61ack or Afrvan Amer an. ' C ^ /wan b~dran D ^ CNnese" 7A b0 :YES : [~0. :^1 C^Yes, Puerto Alran Dj]Yes, Cuban E ^Fipiw f^Japanese 6^. Korean H^Vielnemese E ^. Yes, Omer SpanisMihparuULadnd (SpeayyJ J ^ NatNe Wwaiian K ^ 6uamaoian a Chamorro :. " M^ Samoan 11 DECEDENLS EDUCATION Ghear the bornw besitM M'~TdeJ~mkvm'dsdaol rsunpkleanthe lane waum. N^Americanhld'nnmAlaska NaQye /sPeefN}- 78 L^ 5 eB~ grade 2 ^ 9drt2m pnde; rmdiploma 3 ®Hqh sehod graduate ar 6ED - - 1 P ^ Other Arun (syecdy} R ^ Oltcer Pacdrc Islander (speatyl q,i] Same coAepe credit bNne degree S ^Assoaalesdepree _ 6 ^ BuBlelars degree - S^ ONer (specry) 7^ Minds degree e^ DodoratrlPrWesslonal degree 92SOCIALSECURITYNUMBER: 13.MARITALSTATUS: : NEVER MARRIED MARRIED WIDOWED bIVORCEO SEPARATED 14.SUAVIVINGSPOUSE: fn¢rrdmeit marrred orseparekd. 1(surNVirq spouseu - ~~ ~Id A U13+.W rA:1 N~7.DLE ^t...: ^p [~ ^4 ^.5 wile. enw mMen name t5A USUAL OCCUPATION. (Do noterrterrehred} 1158. KIND OF BUSINESS OR INDUSTRY. 115C.NAME AND LOCALITY OF COMPANY OR FIRM: i ~Cer I ~WIl HOme ~ _ IDENCE CaunryorRegion/Provlnce 168 16C LOCALITY (CheckoneandspecrtyJ : 16F.IFCFTYDRVILLAGEISRESIDENCE LLAGELIMITS? TY R I SI 16A RES ( stateorcounhy N York . it notllSA: ss h Dut VI Iy1THINCI O CITY :VILLAGE TOWN W3p~]inger5 ; Es ^NO IFNO,sPECIFYTDwN ew drrorus4J e c ^ ~ ^ Fa s 16E. ZIP CODE'. 16D STREET AND NUMBER OF RESIDENCE ~ " ' I I 12590 ~ Y. N lls F 25 I . , a Apt. 1311, Wappingers 72 Trial Blvd . , 17 NAME OF FIRST ' MI LAST 16. MAIDEN NAME FIRST MI LAST OFMOTHER_ 3o FATHER Jessie Adam Dodson Dorothey Bell Hopkins 19A. NAME OF INFORMANT: 198. MAILING A9DAESS: (include~p cadet Kodak, ZN. 37764 i 2746 Roberts Road , Gail Qark 31 - 20A tOeDluu 2 MAnoN aOReMOVU AoRDED 5DooNAnox 1208: PLACEOFBURIAL;CREMATION,.AEMOVALOA-0THERDISPOSITION. 20C.LOCATIDM(Clryor7ownandstafD) - - 6 ^ENTOMBMENr MONTH DAY YEAR 12 03 201"2 IPou hkee ie Rural GYemato (Poughkeepsie, N.Y. ADDRESS DF fUNFAAL HOME 218 REGtSiAATION NUMBER Y N l 3,e '; 21A NAME O. . s, . -i 00440 _ Funeral HoliTte 64 E. Main St, Wappingers Fal Dele~nty 22A NAME pFfUNERALDIRECTOR. 22B, SIGNATURE OF PJNERAL DIRECTOR: 122C. REGISTRATION NUMBER: i i ~ DF, 10885. ~ ;(,~„ Kevin A. Delehanty E 23A BIGNAIURE OF REGISTRA 235eh~ flLEDDAY : Yf~,a 24A. BURIAL OR REMOV hIIT IS D BY: 24 ISSU ~ Y TEAR y ~ I -7 , ~ z t f b as L_ . ITEMS 25 THRU 33 COMPLETED BYCERTIFYING PHYSICIAN-OR -CORONER/COHONER'S ICIAN DR MEDICAL EXAMINER 25A CERTIFICATION: To the hest o1 my knowledge; death occurred at the time, date and place and due to the causes stated. _ 0000 Oerti4er s Mame /~r 1 ~/'J•Yl iS ~'t~l.l'~Z ~~ License No.: - Signature. Month Da Year on behall of Atte n ctin ^ P ~ ' r nding Physaan Address ~ ' CANCER q a h cia sTitle 0^ Attendmp Physlclan D Certifier a!.. "' hk e P r e ell ~ I Z 6 e~ ~ S~ / o%t R e n _ 1[] Coroner 2 ~edid Examiner) Deputy Medlca[ Examiner . Monts Da rear ..258. K coroner a not a yhgsiLdan, enter Cororrer'S Physician's. name~litla: liceree No.: Slpnature: '25C. B certifrer a not atfeadinq phys~~8n order AttendlRgPhysieian's name 6 title 'llcertse No Address: ~:6A, Attending Ohysician Mwiq D Year. Momh Year Z68 Deceased lastseen alive Moran Da Year 26C: Promuuxsd MmM D rear rune ocav pN ~` 2 ~ dY allendlnpphysklan ; l Z AT 13 ~ ~ M ~ . e ~ atterded deceased To UNDETERMINED - PENDING 23. MNNNEROFOEATH' ~~ 2B WRS CASE REFERRED TO CORONER OR MEDICAL EKAMINER7 29R AU70PSY'r 298. IF YES. WERE FiNDINGSUSED TO DETERMINE ND YES REFUSED I CAUSE OF DEATH? C~c .ACCIDENT HOMICIDE SUICIDE CIRCl1MSTANCES INVESTIGATION iJANRAL 1 ES ^ ^0 ^1 ^2 I O^ND 1^YES , [J'1 ^2 ^3 ^4 ~5 ^fi : 0 NO.. u \ CONFIDENTIAL SEE INSTRUCTIDNSHEETF0RCOMPLETING CAUSE OFDEATH CONFIDENTIAL (-~ ~ f" - APPRCRIMA7E INRPVAL 30. DEATH WAS CAUSED BY'. (ENTER ONLY ONE CAUSE PER LINE FDA (A}, {B), AND (C).) eErwcEal onsEr AHO oEarH ~ PAATI IMMEDIA CAUSE ~~ I. -pUE TDDRAS A C UENC OF; I '(B1 a n - L..,.. ~OUE TD OA:AS A CONBFAUENCE OF'. I ' IDI ~-~ DID TOBACCO USE CONTRIBUTE TD DEATH? PART II OTHER CIGNIFICANT CONDITIONS CONTRIBUTING TO CJZ 1o h rYrrA j JYLZ> ~'~ ^ PROBABLY 3 ^-0NKNOWN S ~ ^ o ~ YE 2 0 NO T DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A) d ~ ~ p 31A IF INJURY. DATE HOUR 318: WJURY L(JGALITY (Cdy ortown and county and state) 131C. DESCRIBE HOW INJURY OCCURRED: 131 D PLACE DF INJURY: 131^}ED. INJUR EST WORK? o ~ " o MOIrTH DAY YEAR i l I ^ 0 ^ 1 m : _. ~ ° ~~ 91F IFTRANSPORTATIDNiNJURYSPECIFY..: 32WASDEDEDENT HOSPfrALlZED M NO YES 33A IF MALE: 338 DATEDFOcLIVERY; ar t MhtAH DAr YE1R ^Pregnmta omcdtlMn Z^tlolprepwM1 MDre9~I NaNn ~2 tlays ol0ate Mtim tc M ~ Via, ,~ z ~- 1^DmeiAlperna 2^Pasaiger.3^Pedesnun ~^ QtREA ltpmtyl T3: ONI}iS? ^ B ^ 1 y m crearort ¢ pot i-~ 3 r_l Nw DR9nlnt GN D~/3 dm ro ~ rex Mort aratn A ^ Udamm n me9~um witlr'ui pxt yw P La.r JIUZGUAIIYh uero usA LOSSfoos+azM osnt G~ 4P ~f .., _ ~Q ~~ ~ - -. 9o s~ y Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section __ S - v:::::::>::<:;:>: : :::: Y Z FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. :. F.:. ry...1..r ,L.:S::.: *': n.v: x::. :.\ ................ •:: F.. .. hji S'.'iC .'•M .:~::• ;:%S:'•:: ::;::::: ::•::..:..... Y F,, SSi •... ... ~..., ti':i•:•in:~~55:<:iL<Li:•:,vk3. •v. ,•1:••/:::::::. ~ ::::;:::.1.. . ;:.; .:..::: .SY...,......:•::.. ~. ~:::. ~:: /'..,:... ...>....:t•:.... .. t r:.?.:i....:.•',~.: ..f •: \: ~: iY.t•:'i2~S:fi::^.,.Uti:iYiiiiiii'•i~ i::i':'ii:::i::i:= ,kF,.:::+. •, :'vY. R.:. :,•.3..,•:..v,.,,,...: ..:: m:::l ::::.:::::. .. ~:~ ..155 155:: s.,:S;Y ;;::,~ .o`''" ...,.:t: ..................... •x Fi%. Name of Deceased ~ ~ ~~~ ~~~z~~y 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 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 ,Taws or C' Coun Purpose for Which Record is Required ~c~ ~~ ~rc~,~e~ ~t ~- What was your relationship to the deceased? 1-- ~--~ ,~"N~~rc r,ev~ C In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~'~~'~~~--~~ r - Date / ~ ~~ /i '3 Address of Applicant i ~ /F"' a ~~~ .6~~~G~ /% Cam/ ro,~o,~ ~r_~ ~~S .~r/~ 1 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death ;_;. :. .... .> <::;i::55S:;jjS,i;#:''•::r5:&;y<::5':; .7 :}:`tt liiiti:?::':;r,.';'%:~,,;::r:::?.:>i Name --.N ~. Vim, .~ r ~. ~ 7,h , fi Address / if M ~ ~~~~~ ~ ~S ti ~h city / J ~„~ ~ r ~ p ,-~ ~~-//s state ,/a/`t~ ~ ?ap Code t a.5 Y v K DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for L`opy Of Death R@COrd Vital Records Section lTii± FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ... Name of Deceased ~ SC e ~-'~' Date of Death o Peri d to be Covered by Search ~~(Yct~ .~ ~ J First Middle .Last i S Name of Father of Deceased Social Security N ber of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death IZ z 33 First Middle Last Month Da Year `~ Place of Death Q v cam; r~ l2 ~ ~/ i~ ~~ l~ ~'^-'~ ~ "12 Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? /~ Y S ~~ ~''""S If attorney, name and relationship of your client to deceased Signature of Applicant V ~~'''~ ..: ~~ Dat ~ /U ~ 3 Address of Applicant '~ ys ~ (~ ~ ~~~v~ ~~ ! 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 Record Vital Records Section PL:ItrASE<COMiPLETE Ft)RM AND' G~ :E FiF,E' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PI.~ASE P RINT QR TYPF Name of D/eceased / Date of Death or Period to be Covered by Search / t~ Q JN ~ ~{` G 1'f C r I W ~ ~b COY , First Middle Last ~ /~ r;? ~ G Name of Fa//ther of Deceased // ~ Social Security Number of Deceased ~vula (,r/r/9~/' First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last onth Da Year Place of Death u sun ~ ~ 2 h Name o Hos i al or Street Address Villa ,Town or C~ ~~ ~/~f Coun Purpose for Which Record is Required /` What was your relationship to the deceased? In what capacity are you acting? l~a~~, If attorney, name and relationship of your cl nt to deceased Signature of Applicant Date ~ -~ Address of Applicant ~ ~ ~~ ` Number of copies requested with confidential cause of death >-? -=~ '~ Number of copies requested without confidential cause of death FEB 01 2013 ~~G~R ~~ Name _ Address City - State Zip Code DOH-294A (6/2000) .~ STEPHANIE M. WHIDDEN ATTORNEY & COUNSELOR AT LAW P03T OFFICE BOX 249 WEST HURLEY, NEW YORK 12491 PHONE: (845) 338-6500 FAX: (845) 338-8498 March 25, 2013 Town of Wappingers Falls Attention: Town Clerk 20 Middlebush Road Wappingers Falls, NY 12590 RE: Estate of James J. Lyons Date of Death: June 20, 2008 Register No.: L324 Greetings: EXPRESS MAIL ADDRESS 90 ST. JAMES STREET KINGSTON, NY 12401 I represent David J. Lyons the Executor of the Estate of James J. Lyons. Enclosed please find the following: 1) Application to Local Registrar for Certified copy of the Death Certificate of James J. Lyons 2) Check #5235 made payable to the Town of Wappingers in the amount of $10.00. Please return in the enclosed stamped, self-addressed envelope. The purpose of this request is needed to open the Safe Deposit Box located in the First Niagara Bank located at 1555 Route 9, Wappingers Falls, New York, to close the Estate. If anything further is required, please call. Very truly yours, ~~~ STEPHANIE M. WHIDDEN SMW:pm Enc. Sworn to before me this 25t'' day of March, 2013. 1 ~'t1~~~ ~n~u~e Oount~l Notary Public ~} 4 ~~ ~s~3oa ~j13 tld~~l~~ ~~ ~~~ a wrrr'.r Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section for Copy of Death Record _ PLEASE CQ~MPLETE FORM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PR{NT OR TYPE Narne of Deceased Date of Death or Period to be Covered by Search J A M rr 5 G-. BEevnlE7'T First Middle Last ~-/ d- .~a i 3 Name of Father of Deceased Social Security Number of Deceased J H M 65 Q~evn/ Err First Middle Last j l G- 3~- 5S 4 d; Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death /VIIL.DRE> CoCh/kAN,~ '" ~% > ~ ~ ~'~y ~ h' First Middle Last Month Day Year Place of Death ~G~ ~ M&SecR L} ~/~. (,Jf~Pe°en/G~~PS FAILS Tju~ c:H~SS Name of Hospital or Street Address Villa e, T.a~wa..or1~y County Purpose for Which Record is Required 1 U S~TTL~ E_STAT~ What was your relationship to the deceased? >'-[l~t lE2gG Dig EG7o R- ___ In what capacity are you acting? ~AM~~ ___ If attorney, name and relationship of your client to deceased Signature of Applicant ~- Date_ 3 ` ~ 9- ~-~' -.-- Address of Applicant ~~ ~ /?il,Qin~ Si. uJ~P Pe~ c=EQs GAL~s Ny /25y() ___ COMPLETE FOR DEATHS QCCUF{RING AS OF JANUARY 1 19$8 _ -`~ Number of copies requested with confidential cause of death _____ Number of copies requested without confidential cause of death PLEA5~ ARI.II+]T NAME ANp A[~QRESS WHERE R~CQRG7 ~'HQIJL.t~ BE SENT Name ___ ~ _ Address City State Zip Code _ DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH . ,.._~ .-,----.~.. ~....~t..., Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Cert~cation. Please do not send cash or stamps. Nam of Deceased ~. ~~e~~ Date of D,eLath or Period to be Covered by Searc ~ ~ 0 e ddl M ~ L~ T i First Name of Father of Deceased ~eyLyloi~ ~ Social Security Number of Deceased ,~a~n . o First Middle Last Maide~nnName of Mother of Deceased C ~'' 1 121, Y10 n Date of Birth of Deceased ~O ~ ~ /g ~ ~ Age at Death `~~ a / First `c Middle Plac of Death I I ~ Last o Month Da Year l u ~ ~ D ~ e Name of Hospital ar Stmt Address Villa ,Town or Ci Coun iced Purpose for Which Record is Req ~ tiro IJc~~ e U~ lJ What was your relationship to the deceased? v r In what capacity are you acting? s e If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant _ ~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 0 2013 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 - X10.00 iper certified copy ar Mo Record Certification Identification Requirements: App ication must be submitted with copies of either A or B. (Note: Copy of Passport required if request is rnadefrom a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -QR- 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: Thomas A. Alexander 094-30-9259 First Middle Last Date of Death or Period to be Covered by Search: (mmiddiyyyy) Date of Birth of Deceased: Age at Death:. 03/03/2013 08/12/1938 74 From To mm / dd 1 Maiden Name of Mother of Deceased: Death Certificate No.: (lfknownJ Sarah Jane Williamson First Middle Maiden Last - Name of Father of Deceased: Local Registration No.: (/f known) Herbert W. Alexander First :Middle Last Place of Death: 316 Myers Corners Road Wappinger Dutchess Name of Hospdal or Street Address Village, 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 Total number of t d ~ i es reques e _ ~ confidential cause of death 4~ confidential cause of death cop 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 chi'id of the deceased or the spouse of the deceased at the time of death, .you must submit documentation of a lawfu'I !right or claim. Date Signed: FOR REGISTRAR'S USE ONLY Signature of Applicant: Moron oa veer (Phatacopy iD and attach to application form) 03 04 2013 Type of ID; Driver License i ~ ' r Address of Applicant: - Issuing state: ~ ~~,..~~- Anthony J. Calabrese Expiration date:: 3 MAR~~~ (App6canYs Name) NUmber: ^ Other'ID, Spec~~~ ~ •;,. ;~~} 900 Route 82 , p 4 _ (Street) NUmbe'r: ~ pw . Hopewell Junction NY 12533 Type: (City) (State) {Zip) Number: Telephone No.: ( )(845) 221-9234 Type: DOH-294A (06/200/// 5~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of D ceased ~~~: ~ 2- ~ ~ ~~,z~ ~ Date of Death or Per' d to be Covered by Search , r ~ 3 3 First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Da Year 11 ~ Place of Death ~ ~ ~ ~ ~I ,` J-~,~ (\} ~ J ~ U c s S ~ I Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpose for Which Record is Required ~-~~~1 What was your relationship to the deceased? In what capacity are you acting? ~ If attorney, name and relationship of y ur client to dec ed J I Signature of Applicant Address of Applicant _ U 1.~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name K -.~ -'2--e' W ~(i" ~ - ttr~J Address o? ~~ ~ ~ 1" five ° 1 ~ `S City 1,yY~,~ -'NG---e4'L State ~1 Zip Code DOH-294A (6/2000) Application to Local Registrar for Cop of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section :.7 .; ;$,;}. :: M,;: :•N: :.:~:. f. f:: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. .............. .........: n:::::::: v::: v•.v. n... ......:..... .. v: },+- .;^J:v;•.},.},.:.•w v:::::.:. 44: :J:... : .,v,.}:}:~}};L!Ly::•:v::•i'n;.,v,.}:5::2•:v: }: .,:i.;,{ .r.. .. :).:.. S.C... :tixw.~::. {~, •\.; :.}:•~Y.:{...; .:.Q :Y•v•:i~/i ;?t; r:?::, :;•ry; ~:i~i3Cii4:• ~:v :<:5::'vi~L$i.::~;.1.~.}A}::•n.}}.k~:}ii:.vh>.:Yfi; {{,n},.{: r.:~ v:: i:x rn. . ;~ . • ... ..}..'.:r: :v~:G}:'•Y :{?:i:}•4>>.Y i:.yv'i }': ••v. .:}:~%.si'i'v:>n:v..::nw ....:::.~n5:>:2::~.~:::..:~:- : -. i~'N '^:.K.. i.'.v: v: {::i ~ `. ::%} ::}..: ~~:: :;,}`::::::: h.4}.i:SY•.x..2•r. }i:::i?:2?ii:.iY:.}.i:•i:}:: }v:~+: :L6::.::?•Y:.:: _ of Deceased Name 1 Date of Death or Period to be Covered by Search R~~,ra ~:1~~ 031~~1 ~~ ~ ~ First Middle Last . Name of Father of Deceased ~ Social Security Number of Deceased ~ ~ r _ First Middle Last -- Maiden Name of Mother of Deceased Date of Birth of~Deceased~,~ t ~ ~~~ .Age at Death 79 First Middle Last Month Da Year Place of Death (~~` t\ 0~ ' C .Name of Hos ital or Street Address Villa , T or C oun Purpose for Which Record is Required What was your relationship to the deceased?' In what capacity are you acting? +~,~,w Y.~~~c,o~n~ ~ If attorney, name and relationship of you lient deceased - - -~y(,~ ~ ~ ~~ , Signature of Applicant i ' ~'M ~ ~ a Dat ~'~\ S Ny ~ '~ s ~ ~ ~ Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death •}:-0'+•}:• :SV .:Cii+i'ri F:. r:•iM1V'.Li'i{:'i%3C: $~::S~..Y::r'i'i::: :. i Wi:::;:::::. .O: v...:. . ., .... .. •..u}•. .. • .. Y' Name Address Cry State Zap Code K k Application to Local Registrar for Copy of Death Record DOH-294A (6J2000) NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 /Other Districts - X10.00 ;per certified copy or No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is:made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B. Two (2) of the following showing the applicant's name • Driver license and address.: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: Richard G. Barger 084-26-7845 First Middle last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 03/19/2013 11/24/1933 79 From To mm / dd / Maiden Name of Mother of Deceased: Death Certificate No.: (tf known) Helen Linser First Middle Maiden last Name of Father of Deceased: Local Registration No.: (tfknown) Fred Barger First Middle Last Place of Death: 14 Widmer Rd. Wappingers Falls Dutchess Name of Hospital or Street Address Vittage, town or clty Counfy Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death confidential cause of death copies requested ~ Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or chi'Id of the deceased or the spouse of the deceased at the time of death, you must submit documentation of a arwful rFght or claim. Date Signed: F"fJR REGISTRAR'S U$E ONLY Signature o pplica Moen oa, vear fPhotcrcc~py ND 2~ attach toapplication formj 03 20 2013 Type of 'd D: Driver License Addr~ Applicant: Jssu~rng-stat~e° Ginny L. Servay Expiration date.: (Applicant's Name) Number: 1028 Main Street ^ Other 1D, Specify (Street) Number: 4 Fishkill NY 1252 Type: _ (City) (State) {Zip) Number: Telephone No.: ( )(845) 896-6166 Type: DOH-294A (0612005) _~ ` 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 First Middle Last Name of Father of Deceased "" ~~ Social Security Number of Deceased ' ~I~~--T I~1- ~ 3S 3-o3-0`7~~ i4 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death < I V ~ W ~ L1./~ 1 f J.1 First ~ Middle Last Month D Year Place of Death Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Requir ~-- ~~ S ~ ~ ~ ~ v~ What was your relationship to the deceased? ~ ~ ~-~ ~ ~ p-Y' In what capacity are you acting? nship of your client to deceased If attorney, name and relati o Signature of Applicant 45--~1~ Date ~ f c~~ 1 ~ 3 5 ~ `- Address of Applicant n U f J ~~ ~ = ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000) ~~ ST ~' c~.ass ,~. , ~. :z ~,;~: F ~~~, . ~~. ~» JO+IRES.l13-2747 v~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PL.fMASE COMP>xETE FORM AtxlD ENCLOSE F~~ FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Pl.,lwASE;'P~tNT`4Fi TYPE Name of Deceased First Middle Last Date of Death or Period to be Covered by Search ! [ ~/ l ! 3 Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Da Year Place of Death c~s- Ec~gr. /~~l( 1~.~~ L/-~~~~~~rs ~~~~s /(~~ ~~~° ~~`~c~,rSJ Name of Hos ital or Street Address Villa e, Town or Cit Count Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? Lc.-~ ~n 7Ynf~cr~,~.,~ If attorney, name and relationship of your client to deceased Signature of Applicant ~~ --~~~Zs' ~~ ~~9'~~~ e- ~~ Address of Applicant '~ ~ ' t..J 174 ~%~~~ - 1~i ~-:~:i Number of copies requested with confidential caus~ of death APR 1 6 2~?~ Number of copies requested without confidential ca~s~o~h~,~s- ~~~b~ ='~~`~INGER DOH-294A (6/2000) Applicaltion to Local Regrstr~ir NEW Y01=tK STATI:_ DEPARTMENT OF I-IEAL~fH vital Rerc,rils e,aic,-, for Co of Deeth Record RI:EAS~ eS]MPI..~TE FlJFtfu1 ANp ~N~I~USE :FED FEE.: :1;10.00 per copy or No Record Certification. Please da not send cash or stamps. ,, f~G,;~A~~ PRINT QR TYPE ` Nome of pr,ce~sr.:cl r a ~ ` ~1t' ~' ~d ' .Date of Death or Pi:riod to be Covered by Search 1 9 T1 ~1 4 M Ci ,rl~r~ 1 ~ ~ 2~.?~'~j -" - ~ Fu.`,t Middlc: Last T Name ul Father of Deceased Social Security Number of Deceased f=irst Middle ~ ~ Z~' ~~Z.00 Maiden Name of Motl-er of Deceased Date of Birth of Deceased Age at Death ~~ ~ I al~"1, q~t~S~Kt ~ o~r'~1 Z~G' ~ 18313 '$ ~ Fast Middle ~J Last Monll~t Da Year Place of D~~ith Naryie al kilos -,-t . Stree[ Address Village, own ity Count Purpose for Whicl- Nr:cord is Required t( (~ mind a~ ~-/'1~- ~~~0.i I(~ What was your relationship to the deceased?-~l'1~1~l~, 1-~S ~~ ( In wt-at ct-pacity are you acting? ~ ~1(~ ~1A~ ~ 0 ~ "'1'Ol(~Y11 It attorney, narr-e ~-nd relakior-ship of your client to deceased Sign~-ture of Applicant - D ate ~ - ~~! 13 ~ / 1 Address at Applicant _ ~~ 1~ ~ _~_ - - Ham. _. ... . . ... .....,.: ,. ~ __~_ CIaMNI.~Tr~ FQR D~A`THS'Q~CUFiF~ING AS OF JANt1ARY 1 19f#~ ~ ~;1 -----~Nu~r-her of copies requested with confidential cause of death m ~~~^ ,. :: a , . ,, a. . V _''~ ______ Nun-ber of copies requested without confidential cause of loath _ "- . ~~ , ~ , , ..,~, ~` ~~:~ Narne - _-- Address City __ -- Slate Zip Code ~~~~~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application t® coca! Re~iatrar ~,~® to_r Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ..~wr~ry. Name of Deceased •-.•.~~r wra i `l°s-iG ~ .. - ~ .. --- Oate of Death or Period to be Covered by Search 6R.4y~ `a~assy~S First Middle Last 3. 3!• 20 ~ 3 Name of Father of Deceased Social Security Number of Deceased ®irJ~9'f ~ ,~t~S First Middle Last /02 • Z~/• iSJG Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death /POSE ~iG~YENS e ~ / g /Q,~ 2 8! First Middte Last Month Da Year Place of Death ~-~v~''" ~i~P~~~t/~jE.PS bvranfE's5 Name of Hospital or Street Address Village, Town or City County Purpose for Which Record is Required %~~~~' f~fEVS What was your relationship to the deceased? FD In what capacity are you acting? /~~ If attorney, name and relationship of your clieni to deceased Signature of Applicant Address of Applicant ...__ ... . ....-.._ Number of copies requested with confidential cause of death (p'~~ --~- Number of copies requested without confidential cause of death "~'~~ ~,~ APR d '~ ?nr~ Tp Name _ Address City ` State ~,~ ~r Zip Code DOH-294A (S/2000} Application to Local Registrar NEW YORK ~fATE_ DEPARTMENT QF HEALTH 1~or Co of Death Recorr~ Vital Recnrcls Section .~.-._. _-.-----r.,-.~~..., - - ... . PI:~AS~ e4MPl..~T~ F~Fifu1 AND E,NGInOS~ FED ., .'~'"~'"'"~T FEL.: :~ I D.00 per copy or No Record Ce-tification. Please do nqt send cash or stamps. . "" I~h:~A~~ Nf~INT OFD TYPE Na- , of pc~crs~:-secF ~ ~ ~ .Dale of Death o- Period to be Covered by Search r~~n . ~}ri ~c ~ - - .~ ~ ~ ` First Middy Last Nurnc of"`F~.-thcr of Deceased Social Security Number of Deceased First Middle Last Maidan Nurne of Mother of Deceased Date of Birth of Deceased Age al Death ,fit kv'tav~Fn ~ - z ~ - IQl ~ 0 82 F=-rst Middle Last Month Da Year Place or Du::itl- 1, _ ~~Yla~ ~~ `t ~, ~ ~~G~ Name of t-los -,it~:-I or Sire~t Address Village Town r City Count Pui I.iose For Wh-ch Record is Required ~` ~~~ ~~ What was your relationship to Fhe deceased? ~-s--3LZ. In what caliacity are you acting? ~ ~~~_~-~ _ It attorney, narr-e an ~ ip of your client to deceased Signature of Applicant ___ _~ Date ~( ~U ~~ Address of App6c~u-C _,~ Nil I ~~ ~.~ -. ,:, I 'CQNFhI~~T~ FQR LI~A'THS'QCCUFiFtING AS pF JANUA ; ~ (~(~(~ non( - I~ ~ - r-nher of copies rc;quested with confidential cause Qf death U LII-~~~;~ L \J f~ ______ Nr-rr-bcr of copica requested without confidential cat.tse of death ..___._. APR 1 0 2013 . _ __ . _ ~~~, _.n._ . .,,,~ P~:.~A~~'PF~INT~NAM~.AN~'AI~DR~~S.1/VH~R~ Ft~i~QFtI:J~~ Narnc _ __...___~.._.___~__ Address City ~ _ _..___----____-- ~ State Zip Code 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 ~ 4 ~ t First Middle Las Name of Father of Deceased C Social Security Number of Deceased 9 ~ 9 ~ y ~ ) ~ `O ~ Middle First l~s Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death pir~vrv4- ~~nq Ju~J S"" ~ ) 9 ~, o ~ Z, First Middle Last Month Da Year Place of Death ~~,~~/~ /~-~ c~~~j~ /~j 9P~ ~"'YC~'~J ) V fi~ Y~' ame of Hos ital or Street Address O//~' ~/ Villa i ~~ ~ ~ Coun N Purpose for Which Record is Required What was your relationship to the deceased? J!~ ~~ In what capacity are you acting? L ~" If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant _ Date a ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death .,- Name Application to Local Registrar for Copy of Death Record City ~ V ~ e~ ;~ 0 ~~`NN ~~~ GCE DOH-294A(6/2000 State Zip Code ~ ••. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ..:::.:.::::.,: ::::PL(F~ :...~.~ pf,.~..:..:l~F:3.~ FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. .. Name f Decea/sed ,/J ~~~ Date of Death or Period to be Covered by Search First Middle Nof, Father of Deceased ~-{ . l / ~p ~ Social Security Number of Deceased ~ First Middle last Maiden N e of Mother of Deceased ~~ ~'r~-~ Date of Birth o Deceased /~ ~'~ f~3 Age at Death 7 L First Middle Last Month Da Year PlaJce of Death ~/~ /, i ~~ ~ Name of Hos ital or Street Address Villa T or Ci Coun quired Purpose for Which Record is R e D `~~~~ ~ I What was your relationship to the deceased? 1 y~ ~'~ ~ ~ ~ G ~ ~ 7 - Inwhat capacity are you acting? r ~ If attorney, name and relationship of your clie eceased Signature of Applicant ~ ~ V Date ~ Sib- ~ ~`~~~3 ~ Address of Applicant 1 ~ Number of copies requested with confidential cause of death Name Address City _ Application to Local Registrar for Copy of Death Record Number of copies requested without confidential cause of death State Zip Code =- ~, DOH-294A (6/2000) APR - ~ 2 G ~ :3 ~_ Application ~o Local ~iegrstra~~rll NEW Y~ttK STAI-l=_ t~ET'ARTMENT QF HEALTH ~~r G'O ~~ ~~~~~ ~-~C~rt,1 Vital Reco~rls Ser.lion `" , . P~f*AS~ ~QMpI"~TE F~I~N1 AND ~NCL~OSE EEE ~ ,.::: FEh: :J,10.00 per copy or No Record Certification. Please do not send cash or stamps. '` . ~lnf~AS~ PRINT QR fiYAf* Name of Cieceaserl ~--~~ t ~~ ~ ~lavlr v1 i .Dale of Death or Period to be Covered by Seeirch ~, ~ F ~q ~; ~ r-l , Z a t ~ us t Middle La Name of F~.ither of Dece:asr;d Social Security Number of Deceased (_,~~~; S ~~ Irk OG~ ~1- Z2 - 3Z~.`~ First Middle st Maiden Narnc of Mother of Deceased Date of Birth ofi Deceased Age at Deatf~ ~~n I ~ U T=, a~kow^U k 1 ~ M a~ rz v~ Ld , I "13~ ~ ~ 1=first Middle ` Last Month Da Year Place of peath Name al I-ios ~~il~~ treet Address Villact own o City Count Purpose tar Whtch Record is Required 1~~~ D~ roc z~. _ What was your relationship to the deceased? ~ ~' ~ ^ In what cal-~acity are you acting? CXl ~l~tq It c~~ n111 _ ~~ It attonie narr-e a o y, t nstup of your client to deceased Signature of Applicant _^ Date `I - ~~ ~ ~ Address of Apt.,tic~:rnt __~ ~.,~ 1~ t or;~l hG1~_~'vL 15 P~'~ 1 Z~~~ _ ~ __ - ~.J :. > : ,::; ~ ~ `'` CONtPI.~T~ FQR I]~ATHS'QCCUF~FtING AS OF JANUA Y 1 '19i$ ;: _ -~..-~.a ..:. ~_~ Nwnl~er of copies requested with confidential cause at death ~ n(~,~~~~D Nnrnber of copies requested without confidential cat.tse of death Name _.___ Address city _ __..__. APR 0 b 2013 TOWN OF State Zip Code = ~ Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section - - PiwEASE ~C~OMPf_ETE FORM ANO`ENGi:QSE fEE -' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. pi.EASE.PR1iNT QA TYPE Name of Deceased Date of Death or Period to be Covered by Search William C. Wassmuth Apri15, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased William Wassmuth 111-72-3612 First Middle Last Maiden Name of Molher of Deceased Date of Birth of Deceased Age at Death Kathleen Collins August27, 1976 36 First Middle Last Month Da Year Place of Death 14CAlpine Drive Wappinger Dutchess Name of Hos ital or Street Address Vi11a e, Town or Ci Coun 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 ~~ (, ~~ ~~ ~~/~ ~ V„~.~ ~ ~ Date April 8, 2013 - Signature of Applicant ..~ 895 Route 82 Hopewell Jct NY licant ss of A Addr e pp s Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City State-- APR p 9 2013 DOH-zs4A {st20oo} TOWN O~ ~V~PPINGER TOWiV CLERK Zip Code ~`~ ~ ' 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 f Dece ed ~ /,~`~ /~~~ Date of De or P rind to be Covered by Search ,~!~ ~ dam, ~ ~ ~ ~ / G~ ~~ /~ First Middle Last Name of Father of Deceased Socia{ Security Number of De~g~ First Middle Last Maid Name of Mother ceased ,, Da a of Birth of Deceased Age at Death fiddle Last Month Da ear First M Place of D th 9~ ~ ~..-~ Name of Hds ital or Street Address Villa or Ci Coun Purpose for Which Record is Required -What was your relationship to the deceased? ~ ~ In what capacity are you acting? ~' If attorney, name and relati nship of your client to deceased Signature of Applicant " Address of Applicant ~ ~ U ~/~/~.~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City _ pR 12 2013 State Zip Code DOH-294A (6/2000) ~r .- - . NEW YORK STATE DEPARTMENT OF HEALTH \/ital RnrnrrlsciP.Ct1011 FEE: $10.00 per copy ar No Record Certification. Please do not send cash or stamps. ___ P~,EA~E P:RItVT OR fiYP Name of Deceased .gate of Death or Period to be Covered by Search ~YYI~ ~tAS~.~ ~ ~ ~~ 1 ~7~ , ~-d ~ 3 Fast 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 ~a~av-c-fi C~`S~~ ~~1`~ ~~ , I~IZ3 8°~ First Middle Last Month `.Da Year Place of Death `,~ r I I ~c~Vt l~ (e,e`n ~'1-~ Y v o~~-v~e ~ ~r1e Name of Hos italtreet Address Villa e, own r CV Count Purpose for Which Record is Required What was your relationship to the deceased? ~~~~ ~~ r~'{-dZ In what capacity are you acting? ~ ~ ~ VYt I If attorney, name an onship of your client to deceased Signature of Applicant ~ Date y ~ ~ ~ ~ ~ Address of Applicant 3 I \~'1`S ~ (~ ~ 'COMPLETE FQR DEATHS' ~CCU.RRIN~ AS ~F JAN AR 1' 19.8' umber of copies requested with confidential cause of death _ I cause of eat ~ ~~C~~~U~~D __ Number of copies requested without confidentia ,~ Name Address _ City __ DOH-294A (6/2000) Application to Local Registrar for Copv of Death Record a f'a i a: ~; ~~. State Zip Code ***RECEIPT*** Date: 04/15/13 Amount Paid By $30.00 Brooks Funeral Home Quantity Transactions Reference Subtotal 3 Cert. Copies '= Death 56055 $30.00 Total Paid: $30.00 Notes: Payment Type CK #6514 Name: Brooks Funeral Home 481 Gidney Ave Newburgh, NY 92550 Clerk ID: ~-F~ Receipt: 56055 ~~~ Internal ID: 56055 Chase Online -Deposit Details Chase Online Page 1 of 1 Thursday, May 16, 2013 Check Details for Check Number 6514 Post Date Amount Account number Routing number 04/16/2013 $30.00 2000045834488 02601288 Check Images (Front and Back) 6514 ~ ,~y~ WNb fsr`o, N.A. 481 Gidney Avenue Newburry~ NY 12550 ~•1Z88'~60 (845j581.8300 4/14/?ots z ~ORr~OFE Y1LlAACOflM4~AEn9LI5 $"30.00 ~(~~ pnll L~O~`lOOw,~w,~www«~wwww~.e~wfr~w,~,K,Rww,R~w~ww,rw~ww~ww,RwRww~ews~,uR ~ LLAli6 { VJllaglOf WA~:Mg6rs ~~~ ..~..,, wnw~eo~.awe ~N000065i4~' ~:0260i288~~:2000045834488a• Q~ 0 ~~z~ -i~,.iz%rv3~.~a'a'a~~iST.:i r+i~i~ ~~v~iv'= a~i~~~.~a~ir'i-'r~icv .i0~o G ` V ~~~ L. V~~ This information is provided for your convenience and does not replace your monthly account statement(s}; which are the official records of your accounts and does not replace any other notice we send you. JPMorgan chase Bank, N.A. Member FCIIC O 2013 JPMorgan Chase & Co. hops://banking. chase.com/AccountActivity/DepositDetails.aspx?PageSource=AD&AI=3 3... 5/ 16/2013 ~,c,_G/.Tao /9 ~,, ~, lri C~~uw ~~~~ 9~. z~v fi~LC~ jt?e+.+tiL Q~~, « ~~'cacn,c.6.v ~//9~J- Qf / ' (/ D Q ~!-~c~ ~U ~ oo~Q~! G~ct~t~ ~ilC4~~iCO l/ Q STATE OF FLORIDA COUNTY OF il.4S 1`~ie foregoing instrument was acknowledged before me this P~1~ (_5~~~''~ bY~~Py,+2.tt~ A5['=~t ~ ~ruho is personally known to me, or has produced_~ ~~ as identification & who did (did not) take an oath STEPHAN OWN Notary Public, State of Fbrida Commissior-~ EE 189973 My comm. expires Feb. 16, 2018 ~~~~ y U ~~-e°~~ ~7~d /~v//D~' ~oU27,,._ -~_ APR 1 8 2013 TOWN OF WAPPINGER TO~lI~ CLERK ~\ .y Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Rarrnrrlc Section FEE: $10.00 per copy or No Record Cert'rficaGon. Please do not send cash or stamps. : .::::.:........:r....................... .: ~ ~:~: .::........ :•,:::::::•~:~ d Date of Death or Period to be Covered by Search Name of Decease James J. Lyons June 20, 2008 First Middle Last Name of Father of Deceased Social Security Number of Deceased Joseph V. Lyons 082-12-9057 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Elizabeth Zahn July 21 1919 88 First Middle Last Month Da Year Place of Death 15 W. Academy Street Wa pp~in ers Fall p Villag e Town or ~i D~.ch ss oun ~ Name of Hos ital or Street Address , Purpose for Which Record is Required This Death Certificate is needed to gain access to Mr. Lyons' safe deposit box at the First Niagara Bank in Wa in ers Falls New York. What was your relationship to the deceased? gone - Inwhat capacity are you acting? Attorn~,y for Executor na ~; d 7 r ynn~ If attorney, name and relationship of your client to deceased Stephanie M Whidden, Es p. , re~resenti_n Executor David J. Lyon ho 's the o of he decedent. Signature of Applicant Date -3 ~ ~~ ~~ '~ Address of Applicant P O Box 249, we pt Hurl P},~ ~v i ~a~ai 1 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Stephanie M. Whidden, Esq. Address P O Box 249 - City West Hurry State ~fi 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. _ '° F~~,,~Q~~ P RINT QR"TYP: Nam f Deceased .Date of Death or Period to be Covered by Search First Middle Last Name of Father of Decea c ,~ ~ ~~ Social Security Number of Deceased Y 111~~ ~ ~1 , a~'~- - ~.,G - 5 ~~ First Middle Last Maic+~~~ Name of Mother of Deceased Date of Birth of Deceased Age at Death u~ r,~ ~~ - ~-3 ~-~~ ~~ First Middle Last Mont Da Year Place of Death ( ~ h_ ~ t/ `JV ~ ~1t~5 1~ 11 Villa e own r Cit County Name of Hos ital or Stree Address Purpose for Which Record is Required ,~?,;,~1 ~ l ~ ~ a~~ (i~ What was your relationship to the deceased? In what capacity are you acting? U~`- ~'~~"~ If attorney, name and relat nship of your client to deceased Straub Catalano & Halve , y Fur~er~~l f ic~rne ~'^ ~ ~_ , Signature of Applicant , , __ - e .. c.c. t:U. t~c~a 1:3! li t can . Address of App ,~~~ 'CDMPhETE Ft?R DEATMS Q~CUHKtNU`A~ ui ~'~ Number of copies requested with confidential cause of death ~__ Number of copies requested without confidential cause of death Name _ Address City T_ State _.,.a.....,._...._-..~. ~~.~~~~~~ .~ ~~e.~ ;~ ~ r~ = ,~ , Zip Code DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section _- - .... __ PI.~ASE t~OMPI"~T'~ 1=ORM AND ~NG4~OSE FED FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ,, , _PI,,~Aa~ P RINT pR T1fP~ _, _. Name of Deceased - ~ .Date of Death or Period to be Covered by Search First Middle Last Name of Father of Deceased II nn '' __ '' \\ ~~ ~, / Social Security Number of Deceased v~Vv ~.. ~ Middle F~ I (~ - ~ ~ -~ ~~~ Maiden Name of Mothe~of Deceased . ~1 Vlk ~ ~ ~° ~ Date of Birth of Deceased `J c~l ~ ~ Age at Death ~ ~ . rrst Middle Last Year Month Da Place of Death ~ f r `~ ~ , ~ i _ p~ ~ ~ ~ V `~J l 't ~ nt ou it Name of Hos al or St~et~ s Villa e, owr - ecord is Required h R Purpose for Whic ~ _~ `. What was your relationship to the deceased? In what capacity are you acting? ~-`~~--V~.~ :'~'~ ~ ,.• If attorney, name and relationship of your client to deceased ~- Straub, Catalano & Halvey S ' FL1flE .P~ll 1-iit)tTl(: to Signature of Applicant - i;> 1•.i19r ~~IEliil :'i!f(:fa Address of Applicant i' appirrgers Falls, N.Y. 12590 EOMPLETE FQR -~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death _,.. MAY 17 2013 Name TOWN ~~',i~I~~IlVCER Address __. r i w s City ~_._ State ~ Zip~Code nOH-294A (6/2000) M~CABE & MACK LLP DAVID L. POSNER ELLEN L. BAKER SCOTT D.BERGIN RICHARD R. DuVALL LANCE PORTMAN RICHARD J. OLSON MATTHEW V. MIRABILE KIMBERLY HUNT LEE REBECCA M.BLAHUT SEAN M.KEMP JESSICA J. GLASS CARLA S. TESORO DANIEL C. STAFFORD MICHAEL P. BERSAK MICHAEL J. CARROLL ANNE B. LETTERIO DIRECT TELEPHONE: (845) 486-6817 E-MAIL: KMahodil@mccm.com TOVviv OF WAI~PiNGER TOWN CLERK 20 MIDDLEBUSH ROAD WAPPINGERS FALLS, NY 12590 ATTORNEYS AT LAVV 63 WASHINGTON S'T'REET POST OFFICE BOX 509 POUGHKEEPS-E, NY 12602-0509 TELEPHONE: (845) 486-6800 FAX: (845) 48G-762L www.mccm.com PHILLIP SHATZ J. JOSEPH McGOWAN ALBERT M.ROSENBLATT THOMAS D. MAHAR, JR. RALPH A. BEISNER JESSICA L. `JINALL KELL`! L. TRAVER MICHAEL A. HAYES, JR. (Retired) HAROLD L. MANGOLD (Retired) JOHN E. MACK (1874-1958) JOSEPH A. McCABE (1890-1973) EDWARD J. MACK (1910-1998) JOSEPH C. McCABE (1925-1981) _o ~-,~,~~1~~ (-'~ MAY u2 ~~. a~jp~$. ~~~'~`? ,' APPLICATION FOR SEARCH OF DEATH RECORDS FULL NAME OF DECEASED: ANNABELLE B. KANE DATE OF DEATH: SEPTEMBER 13, 2004 PLACE OF DEATH: 37 HI VIEW ROAD, T/O WAPPINGER, NY DATE: April 30, 2013 APPLICANT'S RELATIONSHIP TO DECEASED PERSON: ATTORNEYS FOR ESTATE OF THOMAS E. KANE, SPOUSE OF ANNABELLE B. KANE NUMBER OF COFIES REQUIRED: 3 (FEE FOR EACH COPY: $1000) PURPOSE FOR WHICH RECORD IS REQUIRED: ESTATE OF THOMAS E. KANE NOTE: PLEASE FORWARD THE LONG FORM CERTIFICATE. THANK YOU. SIGNATURE OF APPLICANT: ADDRESS OF APPLICANT: KATHLEEN ~`vAHODIL, Legal Assistant McCabe & Mack LLP P. O. Box 509 63 Washington Street Poughkeepsie, NY 12602 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. Name of Deceased ' a ', ~a ~~ ~n Y ~C~l/~ q G~ n J Date of Death or Pero/d to be Covered by Search O ~Z- ~OZ I ~?iv I `3 First Middle t Name o Father of Deceased ~ ~Ch ~ Social Security Number of Deceased First Middle Lit Maiden Name of Mother of Deceased ~,,,~ ~~1c~ Date of Birth of Deceased 12 Is (~s~- Age at Death .S~ First Middle Last Month Da Year Place of Death 7iv ~ ns~ ~- ~h I ~" ~~ (/~ ~ n c r Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required What was your relationship to the deceased?~~a~ ~~~ /!'l G''7 "~ In what capacity are you acting? If attorney, name and relationship of your client to deceased ~ ,/ ~~ Date ~!' T~j~ Signature of Applicant ~ ~ - ~ ~ ~ ~ Z Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Address --" __ _ _. _.. ~._ r~ ~ '- - city = t~ite_=~ ' I ~'~!I~ n zip Code -~- 'v'Nr j 4 ZOl3 TQ~/ ~~~ ~~3 " DOH-294A (6/2000) ~ ', a , ~~. NEW YORK STATE DEPARTMENT OF HEALTH .._._. ~___-J. C•.wtiwr~ 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 ~,~~ N ~ ~-~~?' IMP/.C'~z First Middle Last Name of Father of Deceased ° First Middle Last Maiden Name of Mother of eceased Yy~,~-h ,a ~,q-.v Se rd First Middle Last Place of Death , ~<JGc/p0/~ ~/V Name of Hos ital or Street Address Purpose for Which Record is Required Date of Death or Period to be Covered by Search Social Date of Birth of Deceased Month /C~ Da Village. Town or City J~ Deceased Age at Death ~1 ~~~5 What was your relationship to the deceased? vY -~- Inwhat capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant ~~Q~'~'~~"~ ~'~°~~~''l''L~t' Date ~~~ ~ Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confiderrtial cause of death Name _ Address city ' 3Zip Code >> ~ ~~.. DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital RecorcJs Section R FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. f~trEAS Na e of Qeceased ~\~~ W`- ~~~ ) Last Frrst Middle Name of Father of Deceased Fir Middle Last Maiden Name of Mother of Deceased first Middl~ Last Place of Death _ Name of Hos ital or Street Address Purpose for Whrch Record is Required ~,~ ~-- 1 tom' e Cx:-~d~..i ~ RCNT QR TYRE .Date of Death or Period to be Covered by Search DS-(~~ ~~ ~ I ~~ Social Security Number of Deceased Date of Birth of Deceased Age at Death Month Da Year ~t~. \ Village ow r City County What was your relationship to the deceased? ~s l1~-~~_~ In what capacity are you acting? (11-~-~`~'~~• If attorney, name and relationship of your client to decea d Straub, Catalano & Halvey Fungal t~inrr~e Signature of Applicant as .~ ~ ~-~~~1 I Address of Applicant 1?U. lsux 1'31 c , f~~~~~ IARII'IARV 4' 19RR ~~-- Number of copies requested with confidential cause of death ~__ Nramber of copies requested without confidential cause of death Name r v f - s: } ~~~ •~ Address ~~ ~~~ ~~ r ! ~ r~ City __ State Zip Code DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH ~/a...l Ci.w~r~1c -~'DA~11111 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 i~ ~s~ ~ ~' First Middle Name of Father of Deceased ....-.. Date of Death or Period to be Covered by Search ~,~c1elln,w~~ 3 ~ ~~, l ~ ~3 Last First Middle Last Maiden Name of Mother of Deceased First Middle Lit Place of Death 3 S ~ cr~J'h ~1 ~- Name of Hospital or Street A ss Purpose for Which Record is Required Social Security Number of Deceased 1, ~'~ -- ~ ~~ ~ ~ ~ r Date of Birth of Deceased ~( ~ Month ~ Da 1 Ye: C~~.~pG~,rS c.~s ~<<S ` Village. Town or City .~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name ~~~ ~~~\ ~~ Address ~ S ~ ~~ ~' Cry ~, ~iYdVl.~ State ~~ (7 ~;~Z E ~ ~dW DOH-294A (6/2000) Age at Death ~ ~-1 jD .~~ c~° NEW YORK STATE DEPARTMENT OF'HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.001 Other Districts - ffi1a.00 %per certified copy or Mo Record Oertifica#ion Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is madefrom a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-ID: -OR- B. Two {2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a government agency dated within the • U.S. Military photo-ID last six ~6) months Name of Deceased: Social Security No. of Deceased: Henrietta G. Elsasser First A~tiddie Last Date of Death or Period to be Covered by Search: (mrn<dd>yyyy) Date of Birth of Deceased: Age at Death: 05/03/2013 09/23/1926 86 From To rnm/dd>' yyy Maiden Name of Mother of Deceased: Death Certificate No.: (If known) Elizabeth Bolen First middle Maiden Last Name of Father of Deceased: Local Registration No.: (ffknown) Michael Geske First Middle Last Place of Death: 22 W. Caroline Drive Wappinger Dutchess Name of Hospitai ar Street Address Village, town or city County Number of Copies Requested: (For deafhs occurring as of January 1, 1988 specify with or without conirdential cause of death.) Copies requested with Copies requested without Total number of 10 confidential cause of death 10 confidential cause of death copies requested Purpose for which Record is Required: What is your relationship to person whose record is required? l ~.~ o~ ~(S Funeral Director In what capacity re you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If :you are not the parent or chi'Id of the deceased or the spouse of the deceased at the time of death yo must submit documentation of a 'lawful right or claim. ate si d: FOR REGiISTRAR'S U$E ONLY Signature of A p scant: Moan D v~~ tPhoiocopy lD -and attach to application firm) 2 3 Type of ID: ^ Driver Llcens$ Address f Applican : Issuing state:: .__ ? .-- Expiration dal ; Robert H. Auchmoody Funeral Homes, Inc. (Applicant's Name) N'Umbe'r; 1028 Main St ^ tither ID, S WN G~` `~`v~PPINGER , (Street) N!um ber: x ~ Fishkill NY 12524- Type: (City) (State) (.Zip) Number: Telephone No.: ( )(845) 705-3963 Type: DOH-294A (06/2005) NEW YORK STATE DEPARTMENT OF HEALTH ~ r:...~ o,.,.,,~a~ Cent:nn Application to Local Registrar for Copy of Death Record PIEA~aE ~t)NEp'1:E7E F13RIfA k~ID° NC1.:tr3SE IrEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. p1SE~:PRiNT QR'TYP~ Name of Deceased Date of Death or Period to be Govered by Search Eileen Lucille Stocker May 10, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Linwood A. Piper 006-14-7653 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Elsie Savage October 29, 1923 89 First Middle Last Month Da Year Place of Death BAda Drive Wappinger Dutchess Name of Hos ital or Street Address Villa e, Town or Ci Count Purpose for Which Record is Required What was your relationship to the deceased? In what capacity are you acting? McHoul Funeral Home, Inc. 1f attorney, name and relationship of your client to deceased ~n ~ May 13, 2013 ~~~~'~^' Signature of Applicant t.,/moo -~ 895 Route 82 Date Hopewell Jct NY 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 ____ Zip Code DoH-2saA t~t2ooo~ - ~~ ~ (~1 { ~ - ~- 1 N1~,Y 1 3 2013 TOU111~ ~.~ . ~ :•~4~-~~~I~i~E~ .~ t ~~,, :- 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. Name of Decease ~ ~~~~~ Date of Death or eriod to be Covered by Search 3 ~, C ~ k~n~.~ -e- os b z ~a~ First Middle Last Name of Father o Deceased ~~ ~~ p Social /Security Nuamber of Deceased First Middle Last Maid'e~} Name of Mother of Deceas~ Date of Birth of Deceased Agoe~at Death First Middle Last Da Month Place of Deat ~~ ~~`~ ~~~ ` D ~~'~I ~-1~ ~'.-~ ~c~,~ _ (~-~ ~ C/L- - O Ut Namef Hos ital or Street Address Villa e, Town or C' - Coun Purpose for Which Record is Required ~~G~ r ~m ~. What was your relationship to the deceased? "" In what capacity are you acting? '~ If attorney, name and relationship of your client to deceased ____.. Dat ~~ ~~ ~~ Signature of Applicant _ Address of Applicant f o ~ i"~~~ cu ~^ ~l ~~(~ ~ ° ~' ~ Number of copies requested with coM'idential cause of death Number of copies requested without confidential cause of death Name ~~~ G ~~~~~ Address ~ City /t} ~ („ ~ ~'~~ State DOH-294A (6/2000) _ - ~;I MAY 1 3 20',3 __ _ ;-~~~~.~1GER ~ R. ~' Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section ''PLEASE CUMALETE FARM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PRIN7 OR TYPE Name of Deceased Date of Death or Period to be Covered by Search _~/~NrELGF L- LFTizrq First Middle Last /~ ~'2 r~ 30, :2 o r3 Name of Father of Deceased Social Security Number of Deceased ~ETt~ GE7~a~/t First Middle Last U `~~- `I~' 1fvS'S Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death SyE~/ ,~/AvP ~ First Middle Last 3 /'l /9~'~ Month Day Year ~ rl Place of Death / ~ ,,U. GrLM~2E ©LUD. /tiJf~PP~~,l~ERS ~Fj~LS ~7uTcHFS S Name of Hospital or Street Address Villa e, T County Purpose for Which Record is Required ~~D SETTLE ~ST~tTt What was your relationship to the deceased? ~c~ N~ , PL1L 17i /2 In what capacity are you acting? ~'Qwrt If attorney, name and relationship of your client to deceas ed Signature of Applicant ~ -~i-~-' Q~ Date -~ " ~ ' / ~- Address of Applicant ~ ~ y ~l A / N ST i.~ll~,PP ~Vl>E/~s ~.r~~~lJ~ l 2 SA D Ga~IPLET~ FQR'D>wATHS OGCl1ARIN~ AS OF'JAN>vARY 1 7'988 -~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death PI.~ASfw PRINT NAME AND ADDRESS WHERE RECaRp SMOULt~ E3E SENT Name Addres ~r ? ~ .. _ ~, I City State Zip Code T011Ui~ ~~~ 1~~~r;~E/F TiVGER ~~~~~r ~•~ ~N~ ~~.~ U~' DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH .._._. ~___-J. Ci.w~iwn Application to Local Registrar for Copy of Death Record First Middle Last Maiden Name of Mother of Deceased First Middle Lit Place of Death Name of Hospital or Street Address Purpose(f~or Which Record is Required Date of Birth of Deceased ~ y ~q ~ga'1 u~~.,th Dav Year Village. Town or City Age at Death 8 ~ ~ti,. ~ c~-~~-s S What was your relationship to the deceased? `--'~"J L~-"'~c ~M~~""~ In what capacity are you acting? s'"~`~ c~ l.C~r~ ~L vC~~ c ~~ If attorney, name and relationship of your client to deceased 1 ~ ~~ ~~~ ~ ~" ~ Date n 5 `a1~~ ~ 3 Signature of Applicant ~2-S`~ ~ Address of Applicant L ~ M ~ ~7L~ ~''`'~ ~h .CZ-C~ ~"y ~'~~ Fc~+ BLS , Ny ~ Number of copies requested with corfidential cause of death Number of copies requested without confidential cause of death 'Name Address. City DOH-294A (6/2000) State - =-`~ ;. ~~ w ~ ,_ p`~ ~Ft ~._ NEW YORK STATE DEPARTMENT OF HEALTH Number of copies requested without confidential cause of death FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name, f Deceased ~~ LL ~~ 1 ~~ ~~~ ll~ . ~t'l~ t First Middle Las Name of Father of Deceased ~~~ ~~~ ~ First Middle Maiden Name of Mother of Decease h Middle Lit Place of Death ~ ~~ ~ ~ n t „ ~ r y, ~n..~~ Name of Hos i or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required ~ ~ ~ S ~~- ~_~j ~ ~ ~~ V:-~-~ ` ~ What was your relationship to the deceased? ~~~ In what capacity are you acting? If attorney, name and relationship of your client to deceased ,~~~, ~~ ~ ~ ~~-~- Date 5 2 ° ~.o t3 Signature of Applicant '~,~ 12 S' g C Address of Applicant ~ C~~~~°`` ~ l'`~ "`fin `~ ~~ Number of copies requested with confidential cause of death Name _ Address City - Application to Local Registrar for Copy of Death Record Date of Death or Period to be Covered by Search 1 L- ~~ -~ ~ ~~FS Social Security Number of Deceased ~. Date of Birth of DrecQased ~ ~ L ~ Age at Death .._.~~ ne.. Vcar State 'v'n ~ -Zip Code ~~a l-'~~QI ~' DOH-294A (6/2000) C Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEASE COMPt^~TE FORM AND''EN'CLQSE fEE '' FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. !>P~EAS~ PRINT OR''TYPE' Name of Deceased Date of Death or Period to be Covered by Search ~ L r2G~ g2iCF~~ 5~-5'- ~3 First Middle Last Name of Father of Deceased Social Security Number of Deceased ~ L ~/'~~ ~/?Ic'ELL 3 `f~" ~~ - /G ,~ 'J First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death CAA lt~~RiE -.I U LLB Y ~ 16 a ~-f ~ ~ First Middle Last Month Da Year Place of Death ~ 8' /-~~~ ~"9/ZL~7N~ ~,~ . GJHPP/rlGt/~ ~vicH~i"5 Name of Hos ital or Street Address e, Town Count Purpose for Which Record is Required 7'd Si;TTL~ `S %fI T~ What was your relationship to the deceased? >' U n/ E2A, G .D / ~ E~ i old-- _ In what capacity are you acting? S F~/Yl~ If attorney, name and relationship of your client to deceas ed Signature of Applicant ~ Date ~ " !o ' ~ 3 Address of Applicant ~ ://~E COMPLETE FQR'' DI~ATHS QGCURRtNQ AS QF JANUARY 1. 1988 Number of copies requested with confidential cause of death ~.~~,,,,,,___.~~-/-]~---"'~"~"" Number of copies requested without confidential cause of death 1 ~~ (sj~,~ v t~D PL.E,AS~ PRINT NAME AND ADDRESS WHERE RE RD< ; ....................... . __ Name r T®~~~~ ~~.~~K Address City State Zip Code i DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section _. P1.~~1SE e~IUIP~I~:T~ FORM AND ~NGL~QS~ f=Efw ; FEE: $10.00 per copy ar No Record Certification. Please do not send cash or stamps. _ „ Ph~AS~ P ........................ RINT QR TY.R Name of Deceased - .Date of Death or Period to be Covered by Search 5'~' ~~~ ust Middle Last Name of F they of Deceased Social Security Number of Deceased ~~~.~--k-- 1 ~- I - ~~~ -- ~o I ~3 ~ First Middle Last Maiden Name of Mother of Decease Date of Birth of Deceased Age at Death First Middle Last Month Da Year _ i _ Place of Death _ u p Name of Hos i al or Street Address Villa e, ow r C Count MAY Purpose for Which Record is Required ~~, ~-~?,1~ ~ ~ t~C. G~~ ~-l~~ TOWN O~ ~`~~''~'INGER ` What was your relationship to the deceased? _ In what capacity are you acting? If attorney, name and rel~i~~t ~~o~~sdli~~ ~ r~~c~a FlAll+Di'cl~ HC~~1L ~' Signature of Applicant ~~ ~' P.0.13ta2i 1:31 Date Address of Applicant i er ____ _ _. COMP~.ETE FC1R DEATHS'pCCUFiRIN~`QS OF JANUAR 1' 1988' Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address City ___~ State Zip Code c~ nOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH \/ital RPCnr~is .ciP.CtlOn Application to Local Registrar for Copy of Death Record FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name f Deceased i s ~~r Middle a t Name of Father of Deceased U n st Middle Last Maiden Name of Mother of Decease. First Middle ~ Last Place of Death Nam~of Hos ital or Street Address Purpose for Which Record is Required pR TYPE of Death\o'r Period to be Covered by Search ~" ' I Social Security Number of Deceased ~~`~ o~t~°~~ Date of Birth of Deceased Age at Death Month Da Year ~~ 1~~~, S' " - "~ 'Gillaa Town or City County What was your relationship to the deceased? "` ` " `~ In what capacity are you acting? , .~- If attorney, name and relationship of your client to deceased Straub, Catalano ~ Ha1v~y ~ ~ ~ , ~ 3 Ft,>tnc't'~~i t l(trn~ Date Signature of Applicant -~----~~ ~_...~y~ `i-~<<~ ~,~~f~~, Address of Applicant _,___ _ ~'`~?- 't'~u _ COMPLETE FCQR DEATMS:pCCURRINe>>AS OF JANUAR'ir'<:1' 19~.$ `~ Number of copies requested with confidential cause f de ~ _______ c _ Number of copies requested without confidential ca a of e ~ `=' ' `_~ ! ~ ~°/ h D ,, __, . . WN CLERK Name Address __. City ___ State Zip Code __ C~ nOH-294A (6/2000) ~ ~9~°~' Application to Town/City Clerk l NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Searoh and ^ Certification Fee $10.00 P~ SPY A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parries, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and Fee $10.00 Certified Copy ~u,J Per coPY A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedmgs, or settlement of ~ estate. ^ Nn:~ 4T8 2~~ Du : oms: ~114119g1 Sex: ''v Class: 5yes: ,~ .6ndmce:--- Height: ~omFiAed IEstr: `r` ~,~ ,,,~ wed: oel2onelz :~, Secpires:01 /13!2013 ' ~ ~- E{~C /1LA,N FATFi 1738 ~fAi~ C{2EEK 1~R "~~ , ~ Qd1A'K~R~UI~i PA 18951.,, .¢ ,: NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vrt~ Records season TYPE 4F REC4RD L?E~RE d (Enter dumber of Codes) Search and Fee $10.00 Certified Transcript per copy Search and Fee $10.00 Certified Copy ^ per copy A Certified Transmpt is an abstract cram the marriage record issued under the seal d the townlaty dark. tt indudes the names d the oontractirrg parties, their residence at the time the fioense was issued, date and place d manage as well A Certified Copy indudes all d the items d information occurring an the original record d the marriage. as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage aid certain other A Certified Transaipt may be used as proof that a marriage occurred. detaitrired infarrnatian may be requrced such as: passports, veteran's benefits , court prooeedmgs, ar settlanent d an estate. 8t-idelGroort~ISpouse Name (as recorded on manage license): 1 1' ^ _ l ~U~2.~1 ~~ ~"C' ~ CsZ_ ~ Vu `!~ ~, Lad ~~. Date of Birth: forapariw.~ert~y~ ~ ~ gZ If Previously Marred, State Name Used at that Time: Residence (at time of marriage): Fist t~fi~dda lad ~"~p - ~ , ~ Co~~ &ideltroont/Spaut=;e Nal~me (as recorded on marriag/e'~license): 1 Date of Birth: Z ~ t-ad rrda. Lad t~N.» y If Previously Monied, State Name Used at that Time: Residence (at time of ma 'age}: Fraf ITaMN Lot SIMa ...... _.. Marriage Mfornratlot ............... . Place Where Marriage License Was Issued: ~,,~U~~~,~~.1~5 Tows x Place Where Manage Was Performed: ~el,.~~r~ c~can~ Towner Marriage Certificate No.: ~~r Local Registration No.: ~ Purpose for which record is required: ~ Date of Marriage or Period ~5,~~~,,,.y., ~ ~° ~ Covered by Search: Y~ri.eenor sa.aa tisw: In what capacity are you acting?: What is your relationship to person whose recall is required? (If self, state "SELF'.) ~,~~~~ ~` s..suf« ~if.s.ahwypridl Msw/dd/y»ry) If attorney, give name and relationship of your client to person whose record is required: ignature Applicant ate: AppNcaM's Phone Num ber. ~ ~~ ~ / 2 ~~~ lI~ ~~~ Name of Applicant: Please print name and address where record is to be sent: I~a.~-~ ~~.1 Address of Applicant: 1 \~3 ~c~-~~ ~' ~n ~ ~~~2 ~ Q~~~ ~ -~11~ ~.~' . I Z~ Z'~5 Cdy Sate ZIP City Sate ~p DOH~Ot (8/11) Pape t of 2 .,ANEW YORK STATE _ • NEW YORK STATE DEPARTMENT OF HEALTH Application to TotimlCity Clerk for Copy of Marriage Record Ydad Records Section TYPE OF RI=CORD rzE~RE p 4ERt~er dumber of Copies) Search and Fee $to.o0 Search and ~ Fee $to.oo Certified Transcript per copy Certified Copy ~ per copy A Certified Transaipt is an absslrad from the nurmage record issued wider the A Certified Capy includes all d the items d information ocauring on the original seal d the townldty deck. It includes the names d the eonirading parties, their record d the marriage. residence ffi the 6me the license was sued, date and place d manage as weU as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage aid certain alher detailed irdarmadian may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof thffi a martiage occurred. court prooaedrngs, ar settlement of an estate. Brid t3roart~l .use Name (as recorded on marriage license): Date of Birth: ~~ ~ ~j21 a~ (~~les ~a~~ .. ~.~.. ..~, l I Fnf ~ Laf 9ir0iaae» ~~ ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): S ties ~~ ~~- 0 -t Z~ n ~ . ~ iw a~ ~ &id roornlSpottse ame (as recorded on marriage license): Date of Birth: Fnf rrlds. !af ern w.. If Previously Monied, State Name Used at that Time: Residence (at time of marriage): r•..e rea. ~ sw. Marriage tnforrt-stion Place Where Manage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: I~,U/~(~i ~~(-~% ~,~--3ch.e~SS C~(CP S~~ n9 ~1 L~nc~ar~ "'°«~ ~ i 3 C~ Purpose for which record is required: Date of Marriage or Period ~~~ ~~ t~ ~ ne ~ ~ Covered by Search: ~~ iq K s.~ der 3 ~1 ~/ 3 In what capacity are you acting?: What is your relationship to person whose record is required? ~ ~~ ~/` ~, t-~ (If self, slate "SELF'.) ~ I F s .en 1 . a F-'~P~+p4 ~/dd1)yly) If attorney, give name and relationship of your client to person whose record is naquired: Signature of Applicant Date: Applicant's Phone Number. ~ ~_ ~n~ ~ ~~ i3 Name of Appli t: Please print name and address where record is to be sent: Address of Applicant: --=` GU~,~ ~~ S ,~~ I /~S'4 ~~ To wN f ~~ r~~/le LAGER Cify Slate ZIP City Scats ZIP DOFf~01 (aI11) Pepe 1 0! 2 ,_ ORI~ STATE ~, ~~~ pRIV E~CENSE 1D. X54 ~ ~ 56Q ~ 'CLASS D ~~E ~`~ ~~ :,,~ . rz~ci~'° as `~ ~ ~ _ Eve ~E: N9NE ~~ Ri B _ rt, ISSUEQ 03-21 12 EXPIRES 10-27Y18 eHSC~u12 ~ NEW YORK STATE DEPARTMENT OF HEALTH Application to TotlmlCity Clerk for Copy of Marriage Record vrtat-Records section TYPE AF RECORD LESfFE d t;Ent~lr dumber of Caries) Search and Fee $t o.00 ef S Search and ^ Fee $~ o.oo per copy Certfied Co PY Certified Transcript P py A Certified Transcript is an abstract from the manage record rued under the A Certified Copy includes all of the items of infamtation ooauring on the original seal of the townlcity deck. It includes the names of the contracting parties, their recall of the manage. residence at the time the fioanae was issued, date and place d manage as well as date and place of birth of the bride and groom. A Certified Capy may be needed where proof of parentage and certain other detailed irrformatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a manage ooarrred. court proceedmgs, ar settlement of an estate. '' Bridel(3roort~/Spouse Name (as recorded on marriage license): Date of Birth: h-+wati..e-..rl~y~J ~CI~CC1bC`a ~1~f1 - ~~ ~'~~ .ww~. a tar ~ ~. . If Previously Married, State Name Used at that Time: Residence (at time of marriage): as r=r~~ ~~ ~~~ xa~~S j~Nv~Yu4 ~ ~ t~l`l wr ~ ~ &ideltroomtS~or<tse Name (as recorded on maniage license): Date of Birth: (a.a.rr~.ern.nioy ~, ~ ~ Co,~~. ~~-. ~Ia~I~~ if Previously Married, State Name Used at that Time: Residence (at time of marriage): 3aaS' fl~~ ~- ~ , ~ M~ .~[,~cc N`l Fnt Iidd~ !ad WCSkc~s-S''~-~ ~ t~\~( Ma~ria~e information Place Where Marriage license Was Issued: Place Where Marriage Was Perfomred: Maniage Certificate No.: Local Registration No.: ~>~ A~ ~ ~ v S To.~ K lei ~ ~,1~~c1,~+. Tew~ ar Purpose for which record is required: Date of Marriage or Period Covered by Search: SS- ~ 1 Irt<i~d oa a ~~ s a~ aola In what capacity are you acting?: Whet is your relationsh~ to person whose record is required? " " f,„„~~~~ SELF .) (If self, state (~~~ SQL ~ ~2l ~ s..eh 1a ~>~t~ ~~ee~rm- If attorney, give name and relationship of your client to person whose record is mired: Signature of Applicant Date: Applicant's Phone Number. ~J.e ~a.~ ~' - ~~~1~~ 33~ - d' 35--7 Name of Appli t: Please print name and address where record is to be sent: Address of Applicant: ~y State ZIP City Sfete Z!P DOH~30f 18111) Page 1 of 2 ~ ~;_. '~ D5- 5~(' ~ EYES E NONE - .,~~ ~~' J~..,~ t;n~na ~ 9 ~ 135UpD: 71-1312 Ex '=-r OS-30-18 ~nausuvo - - ~- May, 2013 Wappinger Falls Town Clerk's Office 20 Middlebush Road Wappinger's Falls, NY 12590 To Whom it May Concern, Please accept this notarized letter as my request to have a certified copy of m marriage license sent to the address listed below. NAMES: Robert Norsek and Donette Ellis DATE: May 12, 1989 WHERE: Town of Wappinger Falls Enclosed is a check made out to Wappinger Falls Town Clerk's Office in the amount of $10.00 to cover the processing fee. Also enclosed is a copy of my current driver's license. Thank you. S s~ rn -~v y-c.¢~ ~-h ~s ~- - cl ~ ~ ~``~ ~U~3 ~~-r'soncr~~c~ ~~ ~~~r~ ~. o~Or~~ ~~~ ~~ ROSEMARY P. PLANZ NotaryNob01-PL6028055W York Qualified in Albany County My Commission Expires 71191 Sincer ly, ,~~1~ Robert D. Norsek 60 Brockley Drive Delmar, NY 12054 (518) 441-5755 (Cell) --__ G~ r, ; ~ i 1 '' r~~~ ~ p ,.,. -~ ~R ~_ __ ~j i- _ _~ . _ _ ! ~~! 1r~I'. [~ ~..,~ ~!._{ ~~ i "M 4'71.'• ID: 2i5 946 669 ~~A~a D .NORSEK 'ROBEgT,O 9yBROCK~~Y flR MAR NY 9211$4 SE))c M tvE.s ~. Hfi 5w6a E NONE NONE ~SUEL1 06-15-it ~ eeeHOSrcan V 'fit NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Y~ Records Sedian TYPE Of F~~Gt~iD L~~~RE ~1(Er~t~lr~~lumber of copies) Search and Fee $10.00 Search and Fee $10.00 Certified Transcript ^ Pef SPY Certified Copy Per SPY A Certified Transaipt is an abstract tram the marriage record issued under the seal d the tawNaty deck. It indudes the names d the oontrarvfirrg parties, iheir residence at the time the license was issued, date and place d marriage ffi we6 as date and place d birth d the bride and groom. A Certified Copy srdudes ati d the items d infarrnation occurring on the original record d the marriage. A Certified Copy may be needed where prod d parentage and certain other detailed information may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage occurred. court proms, ar settlement d an estate. Bridelfiroom/Spouse ,. Na (as recorded on mama a lice Date of Birth: ~~~°t >r~ ~ ~ ew~w.. --~~ ~ S~f If Previously Married, State Name Used at that Time: e of marriage): s (at tin Residenc r~ suae. laar e - ~w ~ 3 ~ ~ , Bridel~roomtS~iouse Name (as reccorded on marriage license): _ ~` c \mn , C~C~-~-~ ~~ Lpf ~N~M Date of Birth: tarapd Goo orarriry~ $ `~ ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~ rr~ t,.r ~'r" >Ularria~eanfot~ttat+~rt Place Where Manage License Was Issued: Place Where Manage Was Perforated: Marriage Certificate No.: Ia~V Local Registration No.: ~~-/ Tows or Tew~ a Purpose for which record is required: ~ Date of Marriage or Period Covered by Search: Ilaniodonor Soriari low: In what capacity are you acting?: What is yow relationship fn person whose record is requred? ( (~1 (If self, state "SELF'.) 1..,~ed~rrin/ ~ R~wp4 1~laa~rrrrl If attorney, give name and relationship of your client to person whose rer~rd is required: natu Appli nt ate: Appli s Phone Number. ~ ~- Z~ - zoC3 2a3 - 2Y~ - 4$~ `F Name icant: Please print name and address where record is to be sent: ~ `Q ~ Address of icartt: r- ~-~/ Q ` 1 Z~©. ~dy mate ZIP City Stets ZIP DOH~01 18/11) Pape t of 2 United States Government MAY2015 ' Afiliation Uniforrrie'd Services ~~ AQencylDes'3r£ment~ Coast 68ard 6cplres. 2015MAY05 MURNAN, CHRISTOPHER M ` ay Grade Rank _ E6 P01 r:n nnvonlinnc Irlonfifinafinn (:arA 370609ffE0 F s ,t ,~ k m oW~~ x _~~ ~ ~' ~ m ~ N of ,~ O N G r~ C CO ~ N o fD IJ zl `<~ ~ v -± N tl N J v, ~ < ~~`+ '~' r'K v r n r n~ n ~ ~ $ w "' A al. -~ fl7T'i' ~ ' ~ ':: s 1 •r' .~/~ , NEW Y~iK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk ~;~,, for Copy of Marriage Record Search and ~ ~e s,ooo ( ~, ~ Fee s,o.oo >~ ~~ ~~ A Certification. an abstract fiom the marriage record issued under the sed of the Hea11F- DeparUrnent, inckidee the names of Use contracting parties, their residence ~ the torte the ticerise was issued sa weN as date and place of 6irtFt of ttte bride and ~~• A Certification maybe used as proof that a marriage oa~ured. A Certified Transcript irdudes ati of the items of information oocuning on tl'1e original record of the marriage. A Certified Trmtecript may be needed where proof of parertfage and cet~rt other detaled irdonnatiort may be required srxh as: peaeports, veteran's benefits. court proceecxrtgs, ar settlement of an estate. 'I PLEASE PRINT OR TYPE Name (First) (Middle) __ _ (L.aeq Name (Prat) (Middle) (Lasg of Groom ~11 S-k7~h~ 2 x/11 i C V~ cue. ~ Nl ud..ti3~ ~ Bride S`/~t-r ~ (,,. y ~ ~l l,. ~L.n1 Groom's Age or Data of ~ ~- / ~ 1 ~ I ~l ~~ Brides ~ a of ~ y /~ ~ / I ~! ~ V B Bah r Residence (County) (Stags) Residence (County) (state) Groom a~~ ~. r~r.,s,~~ -'~'~ ~ e ee ,~+`-,v~ /~G+~~C.~1 n^ Dale of Marriage or Period Covered ~~ f ~ ~ ~~ G ~ M Bride Previously Married, stale Name Search Used at That Tme Place YYttare IB&1ed 1~I8s 1 ~ ~ 17~G ln' Ct~J (`~ c ~ ~ Place whero Wa6~ V .~ ~ ~ C~.. ~ O l ~j ~Q.,-3 ~ Far what purpose is otiorrrtatiort required? what ie your nelationettip b person wltoee record is requaestad? ~~e_ C~ ~V~Gf ! iC~cjt'_, l L (~Q •~ S ~= Meal~.81a1e "serf.' S~C~~ fJtJt~ tec~eJCc C)~~~~tirJl~~ In what y are you acting? ff aMomey: Name and rolafiortahip of you client to persona whose marriage record is required. `>e L. S Signature ~ Dale ~_ ~ 3 --s~.~ a~ ~ 3 Ad~ees of AppNcant n ~ ~ Pbese print name and addreea where w b be sent. s ~l uR, C~~ : s-w P ~ ~ ~ ..~.uz.n L.v~~c S-~ p~L y ~~~~~3 rr-~~-~s-~-S o~ . ~ e ~, ~~3 ~~.~..~ ~ a ~. OOti-301 (s/~) . (PLEASE SEE REVERSE SIDE) 13 June 2013 To Whom It May Concern: I am requesting a copy of my marriage license. The original copy had my incorrect middle name on it. had previously sent the marriage license back for correction but never received a copy back. V/r e Christopher Murnan KRISTIN FRAME NOTARY PUBLIC STATE OF FLORIDA r Comm# EE141624 • ~~'CE 19~e Expires 10/26/2015 =>~~ °~ /~a~i~ srn. or_ ., TM ia,~poap inatrumeM wa~~a~knowledp80 tnrs~de of 7n1'S p~..!' {~ri5 !Y! u!/utr~p PersoneM~' aPPsred nMge me arq acknowkggaC that hN~ instnanerrc voArrtan- ry fa the purpose ezpressea ~ rc_ 1f ~- i ~ >a or r i~p ~f ..~a~ 7 r Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy} Apply to: Town or City Clerk Where license was issued (purchased) * 1881. to present 030.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. 2. License Issued in New York City New York State Department of Health Vital Records Certification Unit P.O. Box 2602 , Albany, NY 12220-2602 www.health.ny.gov/viial records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtydsrlc nycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (8111) Pape 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record vital Reoxds Section TYPE OF RECOl~D DE~FE D (En#®r dumber of Cc~~es) Fee St O.oo Search and Search and Fee $t o.oo ^ Certified Transcript Per SPY ~ Certfied Copy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy inductee aU d the items d information occurring on the aign~ seal dthe town/o>ty clerk. R rtrdudes the names d the contracting parties, their record d the marriage. residence at the time the fiaarse was issued, date and place d marriage as rreU as date and place d birth d the bride and groan. A Certified Cagy may be needed where prod d parentage and certain other detailed irrfamation may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage ocarrred. court proceedmgs, a settlemer-t d an estate. Bri' r: ' use Name (as recorded on marriage license : -_ Date of Birth: S~ h ~av `~~ 1 u rnt~ ~ ~ ~r.~~t:.~.~,r:D.,t 0' ~q ~ r~ i..r arrr t+re. i 1,o~ ~e1 If Previously Married, State Name Used at that Time: Residence (at time of marriage): First IHd~e last County 8Me ~ti rCOrftf~OUSe Name (as recorded on marriage license): r ~ ~e~-y ~ Kai c~t~e. ~- ~ e nn~s~ ~ Date of Birth: ~..a.~~r. -.,~, os~x~~4~{~1 ~ ~ ~~ If Previously Married, State Name Used at that Time: ~ ' Residence (at time of marriage): ~ a~ ~~ C1~e~~~ -enriiS ~1 i~ N tom. __ Marnsgeanforrnatoa Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~`~~~~`,~,~ ~~ ~Q ~ a ''' ~~~ Irr~1 p~ rewr « Tew « Purpose for which record is required: Date of Marriage or Period ~t C_v~ \~ ~\li ~~' C VI` ~ S Covered by Search: Ilurisdoa« ~ Ss~sfi isuc (~ In what capacity are you acting?: What is your re~titmship to person whose record is required? ~,~ (If sell, state "SEEP.) - ~ e~~ If attorney, give name and relationship of your client to person whose record is required: ~~ .,; ;-1 + 1 ~ ,~~ -- ._ ~ ~ ~_ Sign of Appli t ~ D e: Applicant's Phorm Numbe . K w. ~ 1 ~ r ~ ~ ~ ~y ~ ~~ ~"' •~ V V / 1 0 a Na of Appli nt: Please print name and address where record is to be serif' '~ w. -~~ Ad rase d p rcarrt ® ~ ~ 5 City Sfate ZIP Cdy State ZIP DDH~01 (811) Page t of 2 NEW YORK STATE DEPARTMENT OF HEALTH Yrtal Records Section Application to TotitmlCity Clerk for Copy of Marriage Record TYPE OF REC(?Rp. t~E~RE ~ Enter Number of Copies) Search and ~ Fee $to.00 i t Pef SPY T Search and © Fee $to.oo Certified Co PeC SPY ranscr p Certified py A Certified Trans~ipt is an abstract from the manage record issued under the A Certlfied Capy includes all d the items d information occuning on the original seal d the townldty clerk. It includes the names d the contracting patios, their record d the manage. residence at the time the license was issued, date and place d manage as well as date and place d birth d the bride aid groom. A Certified Copy may be needed where prod d parentage and certain other detailed irdamatian rosy be regtmed such as: passports, veteran's benefits , A Certified Trarsaipt may be used as proof that a manage occurred. court proceerlings, or settlement of an estate. BridelGroomlSpotise Name (as recorded on marriage license): Date of Birth: ~~ ~~h ~- '~ ~~ rn t°~ " ~ 7~ ~ / ~ ~ ~ ~ wa~ar. e,.r era w~. If Previously Marred, State Name Used at that Time: Residence (at time of marriage): was. [.,e ~' sar. &idel ' Etas _ Name (as recorded on marriage license): c~d~ t- ~ ~`~~~ Date of Birth: la+w-arra.. rriy~ 3/~~~3 f=.a, waarr ~ ~~ If Previously Married, State Name Used at that Time: Res' ~~rfce (at time of mat~~age): G~~ joi~ R~~l/ ~ /`~- e:C F..f wear. r,ar car adra Marriagalnforntation Place Where Marriage~~License Was ssued: PI Where Marriage Was Perf Marriage Certificate No.: Local Registration No.: rwn ar Two a Purpose for which record is Date of Marriage or Period / '~i" 0/1I'¢ ~ ~L~Ci'3 . Covered by Search: ~/ Q~ Ilwi~d ea a ~ O /a Swab io~r In what capacity are you acting?: What is your relatiorrsh~ to person whose record is requaed7 ~~~~~ / (If self, state "SELF'.) ~ srau for iaei ~ ~ f -= ~,.. l h~ rml aw~ If attorney, give name and relationship of your client to person whose record is rewired: ignature of cant Date: AppficanYs Phone Number. ~/~ Name of Applicant. ~_ Please print name and address where record is to be sent: 1S~f~Liev ~CJ/N~r/ _ Address of Applicant -~------ ~°~-~ ~ .~,,, , ~ R , Cory Stare ZIP SfbM ' • ; ZIP Cdy DOH~3o1 (8If1) Pape t of 2 ~~ MEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record •,w ~ .. ,,; .. TYPE OF'~EGORD QE~REt? +(Enter dumber Qf C.opies) Search and Fee $10.00 Search and Fee $10.00 Certified Transcript ^ Pef SPY Certified Copy per copy A Certified Trenscr~-t is an abstract from tfre manage record issued under the A Certified Copy inductee all of the items d information occumng on the original seal of the townldty deck. n indudes the names of the oorrtrading pasties, their record of Ore marriage. residence at the time the license was issued, date and place d marriage as well as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage aid certain other detailed irfarmation may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof that a manage ocatrred. court proceedings, or settlement d an estate. 13ride16roort~lSpouse Name (as recorded on marriage license): ~m -~ f1-~l ~, Date of Birth: foreyrd6weo/weniey~) v -l n ~ a~~~ ~k ~ A P ~ de os~ ~3/r~~~ ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): t=..r was. t„r ~ arle BridelGro~mtS~ouse Name (as recorded on marriage license): Date of Birth: f ~a wa ~~ ~ ~c~~.r~ ~ Pair-~c~. , .~ ~ . r°•.p.~G»a a ~ I "7~ ~„~ weer. ~ ~N.» as If Previously Married, State Name Used at that Time: Residence (at time of mamage): t~et wear t,.r aea. Mat~iage tnforrrtatit>,tt Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: vJ~~~ ~~e~S Or~-fch eSS waP~- n~ 2rS DlC-tC~eSS "~°"'- ~~°'"- re.n ar ToeA « Purpose for which record is required: Date of Marriage or Period Covered by Search: ,Soc.1a! Sel~vt~eS ~~ o~ ~8~~a1 In what capacity are you acting?: What is your relationship b person whose record is required? ' ~~~ - .) (Ifself, state "SELF s~r r s~~ / ,~...~~ ~,ee,1~ If attorney, give name and relationship of your client to person whose record is required: Si atureof Applicanrt ~ Date: AppticaM's Phone Number. ~ a~ ~ ~~ 6~a- a ~c 3 ~ ame of roan Please pri name and address where record is to be sent: Address of Applicant: S ~( 6rothe.rs R.~a ~' State ZIP Cdy State ZIP 0 DOH301 18111) Page 1 of 2 ~W ~ ILK STATE DRIVER.. ~..ICENSE I D: 357 141 477 CLASS D; ~ ~~`~-~ PATRICK ~_ ~~, M '~MtLY,ANN ~' xo~ 'O Ro :wr ~zsss 05-1 ~~ SF~C F EYES: " W~~'~fii-04 E: NONE ISSUED. 04-30.13 EXPIRES: QS-13.21 eseY~rouwo NEW YORK STATE DEPARTMENT OF HEALTH ~ ~1~PPlicati0n to TownlCity Clerk for Copy of Marriage Record Vital Records Section TYPE 4F ~EGORIa hE~RE _... © +(Enter dumber of Copies) Search and Fee $10.00 Certrfied Transcript P~ SPY Search and Fee $~ o.oo Certified Copy per copy A Certified Transcript is an abstract fiam the marriage record issued under the A Certified Copy includes all d the items d information oocumng an the original seal d the townlaty deck. It includes the names d the oorm'ad'mg parties, their record d the marriage. residence ffi the time the license was issued, date and place d manage as well as dffie and place d birth of the bride and Boom. A Certified Copy may be needed where prod d paentage aid certain other detailed infarrnation may be requrced such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a manage occurred. coral proceedings, ar settlement d an estate. B . roart~ISpouse Nam as recorded on marriage license): ~ ~~-w~ ~ ~~ ~ l C Q ~ Date of Birth: r"e>re~~•~ If Previously Married, State Name Used at that Time: me of morn e): R sid en ce (at t i e ~ \ l - - / p 1.~./~ Fraf ~ Leif `~ Brtdel Spouse Name as recorded on marriage license): Date of Birth: if Previously Married, State Name Used at that Time: Reside rrce (at time of marriage): ~ `/C.t. frif IFdd~ Laef __ ....._ _ _ __ _.. _ Mttrria$Ll tnfot~s~iarn Place Where Marriage License Was Issued: Place Where Marriage Was Perfom>ad: Marriage Certificate No.: Local Registration No.: Q C 6~ ~ ~ ~eie""d F~l Tamar Tam a Purpose for which record is required: ~ Date of Marriage or Period (~ ~ ~ ~~ Covered by h: ~ ~ ~~ ~c ~ In what capacity are you acting?: What is your relationship to person vrtrose record is requred? ~,~~~~ S ~ ~ ~ (If salt, sloth "SELF'.) ~ e Saerd-fx (aa..afiinpp«Lodf ~/dd/riril If attorney, give name and relationship of your client to person whose record is required: Signature Ap nt Date: • Applicant's Phone Number. ' ~ c~~t~l ~ ~ 3 ~ ~ `5 ~ ~Z ~ ^7 ~- 3 c~ Name A icant: ~ ~ _ ~ , l C Please print name and address where record is to be sent: ~ , c ~ ~ c-,t~v~ J Address of Appli ~ . ,~ ~C ~ ~~ ~ ' (Je c( ~ a~ c~~ ~ a_~_~ S ~~ ~ b crry star. zrp coy state zrP (aJt1) Pepe 1 of 2 ~~"' NEW Y ILK STAT :~ ~~ ~, DRIVF~oLICENSE IQ: 458 56$ 796 CLASS 13 ;..,", PllLtCANO'~`~ F `:HJPJ~TH,A TOP '~ ~ i2~ E: NONE ~ P B +'~ .~P.r~.~< !S'SUL~. tit-t0.12 12.1 Q-2~ 41fF6%lODE . 12-1 ,_ . S~(: ~ EYES'. NE1fi- YORK STATE DEPARTMENT OF HEALTH Application to TotitmlCity Clerk for Copy of Marriage Record '' Vital Records Section TYPE Of REC{3RD QE~R~D f Enter dumber of Conies) Search and Fee 510.00 Certified Transcript per copy A Certified Transcript is an abstract iron the marriage record issued under the seal d the townldty deck. It indudes the natrres d the oorrtrading parties, their residence d the time the license was issued, date and place d manage as well as tide and place d birth d the bride and groom- A Certified Transcript may be used as prod that a marriage atxured. Bridie{(3rotxttlSpouse V e (as recorded on marriage license): It Previously Married, State Name Used at that Time: Search and ~ Fee 510.00 Certfied Copy per copy A Certified Capy incktdes all d the items d information occunng an the original record d the manage. A Certified Capy may be needed where prod d parentage and certain other detailfired information may be required such as: passports, veteran's benefits , court proceedings, or settlement d an estate. S~ mrnS Date of Birth: ~~~~ ~ :~~.. C~l!l 0~~(3 Residence (at time of marriage): Fist t~ loot Coanlr SYN &idelGroo~-~1S~pattse Name (as recorded on marriage ficense): Date of Birth: I ~1 C~~O~Q,~ ~?C~~~ ~\~'~ l ~0~7~ ar,~N.» If Previously Married, State Name Used at that Time: Residence (at time of marriagel: IVlarria~a;lnforretation ' ~ PI ce Where Marriage License Was Issued: P Where Marriage W s Performed: Marriage Certificate No.: Local Registration No.: '~~~ ~ w ~ r~ Ewa- .1i v\.~i~l ~1 -+J Pu~ for which record is required: Q ~ ~ ~'~. In what capacity are you acting?: what is your relationship to person (If salt, state "SELF'.) 5e l ~- If attorney, give name and relationship of your client to person whose record is required: Date of Marriage or Period Covered by Searoh: ta.~.d.~o- ~ 1$ ~ ~~ 1../ imryJ ~"~,~ I la••~~t~9 ~•iadirrr~ me o icant: /~ Please print name and address where record is to be sent: 3b l~,nfi "lid ~~ ciry score z~a ,~ ~~ ~, , I ~.-J ~~C~ ~~`n~~C ~- ~r stn. z-P uvnwi ta/nt rape i of z ST. ~_ ,,..moo ,~~ n CLASS D ~, ~ EYES. 5~.,~ ''~':°" fix. tit.?-~ ISSUE() 05-2412 EXPIRES O6'10-20 TKW77'~°'1 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881. to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1807 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Cert~cation Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.ciiyderknyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH301 (8111) Page 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH v,~ Records sedian Application to TownlCity Clerk for Copy of Marriage Record TYPE 4F 1~C4Rfl C~E;~RE~ (Enter ~Iwrnber Qf Cc;'pes) Search and Fee of o.00 Certrfied Transcri t per s Search and Fee $f 0.00 rtfi C d C ID p py e e opy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy includes all d the items d information occurring on the original seat d the townlaty deck. It includes the names d the oontrading parties, than record d the marriage. residence at the time the license was issued, date and place d marriage as wail as date arts place d birth d the teide and groom. A Certified Copy may be needed where prod d parentage and certain other detailed mforrnaman may be required such as: passports, veteran's trenefits , A Certified Transcript may be used as prod tltai a manage ooarrred. court prooeedrngs, ar settlement d an estate. BridelGroorn/Spat~se Name (as recorded on marriage license): Date of Birth: ~~Sarh '~,i,df.lc~ (or.a.ari..~ernvyy If Previousty Married, State Name Used at that Time: Residence (at time of marriage): F..r raas. v,r ~u-ktnE~S~, Nys~. 8tidelC rracmlS~o~tse Name (as recorded on marriage license): Date of Birth: (arayraf i~ee Nerrpy r-..r ~ ~ rre~+~. ~t.t^nard tar ~;,~ri'Gf Svn aiu tr.» ~ ~ Zy l$7 If Previously Married, State Name Used at that Time: Residence (at time of maniage): ~t~~ct~e55 uY a~. MetTiage <In~orrrtation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~~~~~~-5e fs ~ c-~~l.,~sS oy t"~I~y i~-iae~,- ~~ Tewi w Tew~ er Purpose for which record is required: Date of Marriage or Period ,// 1 ,~ /~(dlYIQ Cr ~4ng~ Covered by Search: 16rti~ena s..ar ieer 5 i "1 r 3 In what capacity are you acting?: What is your relationship to person whose record is required? ~/da rrnrl (If salt, state "SELF.) ~ ~~~ s..ea r« ~...digPwi.a) f../dd/mry) If attorney, give name and relationship of your client to person whose record is naquired: ignature o Appli Date: (, IZ t3 Applicartt's hone Number. _ ~~ 5 ~ ~ ~' ~~e o2-- Name A nt: Please print name and address where record is to be sent: i~-r k ~,~ Sc,s, 1~'la~k~4urd Sow Address d Applicant: ~,. fir,. ~ PI `~,~ ° ~ ,cal ~2 ~® ~-~Q,2~ ~H gp~s ~ ~1 s . rC~ y ~ ~S'~,~ City Stare ZIP City Stets ZIP vvnw i ~W ~ it ra8n i m c ~:. i~:4 " ;;>: DRI'VER~~IG~NSE .~ ;: 1C1; SSA p~~ 858 CLASS D p~~,A~ a ~.~F~ '~ 4!. ^' ~ r ~IJ'~2 ~ ~ .. z k CC R. B : ' ~e.,tl~.stn+,»,-;' issuEb: oa-si-oa ORES o3-2a-ia ar~cw ~= James L. Kelly 17671 Irvine Boulevard, Suite 106 Tustin CA 92780 jim@jimkellycpa.com 714-669-8200 phone 714-669-8202 fax May 21, 2013 Town Clerk Town of Wappinger 20 Middlebush Rd Wappingers Falls NY 12590 Re: Request of Certified Copy of a Marriage Record I was married in the Town of Wappinger, Village of Wappingers Falls on August 24, 1969. I would like to obtain a copy of my marriage certificate for social security purposes. I am enclosing a copy of my driver's license and a check for $10 payable to the Town of Wappinger. My residence address if 28672 Bolanos, Mission Viejo CA 92692 but I use the above office address for mailing purposes. Tha you, James L Kelly encl rfl1{I~-'/r1r,~~ /7r--,~ MAv ~ `~ r:3 ~~ } `t~fi~~~EFZ ~~~ l% r~~ ~~~~~ ~ ~ , ~ ,~ ~_~ ~ f: Y1'l S ~ ~,1 ~+ r ' Y 2; 3 Mj. i 1 '~'~~~ ~.~~~ LFO'KELLY~~ ' .2 ~ ,..~BOLAPIdS ~ a:~~ ~ ~ ~' 4,-~ .MI, ION VIEJO CA 92692 ~ ~ ~ ~ '. FfT:5-08 WT 1'!i0 D - .491 RSTRc CORR.LENS ~ ~ ~ -~ .-~ ~~~~` _ .05 1$!2010 235 RB FD/15 Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and Certfication ^ Fee $10.00 I Search and P~ cePY Certfied C°PY Fee $10.00 Per cePY 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 matTiage occurred. •>.:•- - PLEASE PRINT OR TYPE A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. Name (First) (Middle) (Last) Name (First) (Middle) (Last) of .~Ar'wl~ 1~ t/ ~-u- Groom Bride OI,A~I a4 ~' lVt ~"/trr/O Groom's Age Bride's Age or Date of ~'1 ~, 1 ~ ~ ~ or Date of ~ 2t L Z ~ l ~ ~~ Birth t Birth Residence (County) (State) Residence (County) (State) Groom ~uTc,In. ~ S ~ ~~ ~{O2K Bnde ~uTGl~3S ~ ~ YOQ-~- Date of Marriage or Period Covered ~ 5 v g T Z~ i ~ 46 ~ ff Bride Previously Married, State Name b Search Used at That Time Place Where II II rr ' d Was W ~PP `~ ~ LS lu c place Where W~ W ~~Kl(n ~ L'.~'G~ S P ~ ss ue ., ertom ied For what purpose is information required? What is your relationship to person whose record is requested? . dOl,[ ~- ~~ ~ ~'1 If self. state 'self." ~~ L~ In what capacity are you acting? ~ If attorney: Name and relationship of your client to persons wh i d i i ose marr age recor s requ red.~i~ z- Signature of Applicant I ~y Date i~ Z~, Zo/ 3 Address of Applicant Please print name and address where record is to be sent. 17(~ ~ / fed t .s ~/~ # t n co S,~ wr.E7i L, ~~( Tuszt~, ~- Sz-7sro 1~e71 +~~~. ~w~ s~~r~ ~o~ T~ S i t .v ~t 9 2 7 8-a DOH-301 (S/93) (PLEASE SEE REVERSE SIDE) CALIFORNIA ALL-PURPOSE ACKNOWLEDQMENT State of California County of l~~d~i On "/' 21~2~13 before me, ~a~~; ~~ ~'l . ~~~ . ~~~ ~l~tii Date Here Insert Name and Title of t e Officer . - ~ personally appeared KEELEY M. BARBER Commission #r 1895478 i •~ Notary Public -California Orange County M Comm. Ex fires Jul 15, 2014 , Place Notary Seal and/or Stamp Above who proved to me on the basis of satisfactory evidence to be the person(,b~ whose name(,d~ is/~(re subscribed to the within instrument and acknowledged to me that he/std/they executed the same in his/h~f/they authorized capacity(i~), and that by his/I,t~r/their signature(~j on the instrument the person( or the entity upon behalf of which the person(syacted, executed the instrument. I certify//under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my han and official seal. Signature: Si at e o Notary Public OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: ~~.7~-~I~N TD TOWN ~ ~ ~ ~- Document Date: ~-7~I-Zv1~C~ Signer(s) Other Than Named Above: ~ Capacity(ies) Claimed by Signer(s) Signer's Name: ^ Corporate Officer -Title(s): ^ Individual ^ Partner - ^ Limited ^ General Top of thumb here ^ Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing Signer's Name: ^ Corporate Officer - Title(sj: ^ Individual ^ Partner - ^ Limited ^ General Top of thumb here ^ Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing: ©2008 National Notary Association • 9350 De Soto Ave., P.O. Boz 2402 • Chatsworth, CA 91313-2402 • www.NationalNotary.org Item #5907 Reorder: Call Toll-Free 1-800-876-6827 .~. PLEASE PRINT OR TYPE ~~ Name (First) (Middle) (Last) Name (First) (Middle) (Last) Groom ~ E. Vl (~ ~ f ~ 2 "~ S l L V~! g~ TO>4 N t~ ~lT-LE i~ ~ t vi N L Groom's Age Bride's Age a of I C ~ 2 3 ' '~ ~ ~ of ~ ` Z . ~ ~ Birth B Residence (County) (State) Residence (County) (State) Groom ~ !Zt S i 2~ L R l g~ Q~ 1 S (U t_ ~ ~ Oate of Marriage ff Bride Previously or Period Covered S ~;P -` ~ I Z 2 OU ~ Married, State Name Search i Used at That Time Place Where Place Where ea Was 1n1~l~'N(NGEIZ +-W iri.S s ~ P ~ W~1~p I NGE~2S ~.4-c.~S Ny I s u ~. For what purpose is iMormation required? ~ What is your relationship b person whose record is requested? f If self, state 'self.` ~I ~1 ^ ,-,/ a In what capacity are you acting? ff anorney: Name and refatioriship of your client b persons whose marriage record ~ required. . 9 ~ Sgnature of ApplicanMt - Date Address of , ficant Please print name and dress where record is b fie sent. G~~L ~ #2 ~~~ ~,IC`fIN ~Ev~NE , ~~~, ~~~~~ ~~l ~~ ~1 ~I~EvJ~~ ST l.~N~ T L . - s ~~~r ~'_~-~ ~ ~ i'- ~ ' DOH-301 (3/~i) f-~ ~~ (pE SEE REVERSE SIDE) ~.4 '`~ MAY ~~:, ., T®i~ti9f~1 ~, u 9 e 4.~ ~~5~ ~ , ,A 'p a ~~ ;~, '~ i ~ ~ Spg 131 Np,Zft BR011-05-28{2 •.°'-f ~. t#t37 ~ DENSE TO !3Ni>~ _~ ,y('~1N'8 pE+~WE _-~,. i e DRIVER'S ,~, ~.lCENSE lt..._ a. _ ~ Mf `^~ 9a END an NUMBER ~, NONE . S8973T2O8 a~ `- ~ ~ 15 310 23-1984 ~s sex M f®X6`r•'S~70 E i + ~~a 1 z KEV~N p y " ! a 209 MOUN7 HOPE RD '~ SOMERSET, Mq 02726.4703 /Q// ~ / ~ I / ^~-~"~ :SOD 10•p~p10 Rw 07-fSp09 f d s To whom it may concern, My name is Joan Butler Devine. I am writing to you to request a copy of my marriage license that I have lost. I axn interested in,filing for divorce, which is not possible without that information. I reside in Rhode Island and have been told I need to accomplish this by mail. My date of marriage is as follows: September 12tH, 2009.Our paperwork was filed on Middlebush Road in Wappinger Falls, NY at the Town Clerks Office. Attached is my Application for Copy of Marriage Record and a copy of my identification. Thank you. S' cerel - //~~~~ j an~ut ei• evine 4 Brewer Street Unit 2 4 Newport, RI 02840 ., s 6~--t--. vvi. , Wt- `z ,~ /~'L~ ~Otnn»~t~ sSio h ~xP~ r-BS ~Lu(~3 ;, .+ ' i Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ^ Fee $10.00 Certification P~ cePY A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parses, their residence at the time the license was issued as well 8s date and place of birth of the bride and groom. A Certification may be used as proof that a marri~e occurred. Search end Fee $10.00 Certified Copy ~ Per cePY A Certified Transcript includes all of the items of infiormation occurring on the original record of the marriage. A Cersfied Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. PLEASE PRINT OR TYPE -Name (First (Middle) (Last) ~ ~~ ~ Name /~/ (Frcst) pp(Middle) D (Last) /~rwZ f! i4i 2- Cv Gt~l t S' f ~ n C~ Groom ~-~~ a ~ Bride Groom's Age or Date of / ~ !i' ~f /~~ q~L Bride's Age h °~ ~ ~~ d.7 ~ r 4 C~ ~ . Birth Birt Residence (County) (State) Residence (County) (State) Groom D"~ Bnde t:..tl~ Uw"~ ~ Date of Marriage ~ . or Period Covered Jgr'l ~ ~ ~ ` 3 / ff Bride Previously /~ /~ Married. State Name ~~ S~~IA ~ ~ P,l ~! b Search Used at That Time Place where License was / ter ~ ~~~~ n ~Cn 0 Place where ~ /~ , / Q ~y d ~ / Y ~ C't~ ~'~'e~t~ac(CC I~G . C. K~~ . f P ~ Issued er orTr ie For what purpose is information required? What is your relationship b person whose record is requested? PaS~.I~ r ~ If self, state'self.' S~--L~ In what capacity are you acting? If attorney: Name and relationship of your client b persons whose marriage record is required. Signature of Appl' Date Address of Applicant ~ ~/' Please print name and address where record is b be sent. ~ a~ ~scu~~ ~~°~~ r •1~ ~ ~ t~-r~~ / DOH-301 (3/9Ci) (PLEASE SEE REVERSE SIDE) Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers Apply to: Cert~cation Unit Vital Records Section P.O. Box 2602 Albany, NY 12220-2602 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 A{bany: City Clerk, City Hall, Albany, NY 12207 Yonkers: City Clerk City Hall Yonkers, NY 10701 2. License Issued in New York City Apply to the Borough office of the New York City Clerk that issued the marriage license. The location of these offices follows: Manhattan - Municipal Building, New York, NY 10007 Brooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 1908-1913 are on file with the Manhattan office) 1780 Grand Concourse, New York, NY 10457 Queens - (Records prior to 1898 are on file with the New York State Department of Health) 120-55 Glueens Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1898 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. ;~,~NEW YORK STATE ~,~ , ~:~ IQ: 361 X57 273 ~ CLASS"t) E w '`~ ` ~ ~ F,B~~vT ! _~ ~ ~« :lay ~ ,~ EsNONE '. fi NoN6 ~~?. 1&Sl}ED 9922.11 EXPIRES- 10-18-19 soneHicae x: ._ __..,_, .. Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ^ Fee $10.00 Certfication p~ cepy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and ^ Fee $10.00 Certified Copy . P~ cePY A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. >~ :~.; PLEASE PRINT OR TYPE Name (Frst) (Middle) (Last) °~ Name (Fast) (Middle) ~ °~ (Last) ~ ~ ~ ~ ~ u r Groom ,.' ~ ~ n S c~ra I^ ~ Bride ~ ;~ a ' Groom's Age l Bride's Age or Date of ` ~ / ~ ~ 7~ h ~ ~ ~ ~I ~ ~ B Birth 111 irt unty) (State) (Co Residence Residence (Cou nty) Sta te) ( ( F -'~ S S h ~C `~ i~l G ~ I B~r~de ~ tt~~e-V~ ~' ~ ~ ` I ~ . - ., room Date of Marriage ff Bride Previaisly or Period Covered ~ ~ ~ ~ ~ Married, State Name b Search Used at That Time Place Where ~ r Was ~ -S a Place Where Marriage W~ ~ S~~c~ ~ ( t~ 1 / 1" ~`~1 ' Issued ~ Perfom~red For what purpose is information required? What is your relationship to person whose record Ls requested? " ' ~~ F /1^f If self, state self. s-t? In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Sgnature of Applicant Date J ~Zl~ Address of Applicant ( 1 ~3 v ~~s~ Please print name and address where record is to be sent. a ~ p ~ Te- r~~s%1~ ~ i~, N 7 ~ z~ z~ DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Yrtal Records Section Application to TottmlCity Clerk for Copy of Marriage Record __ TYPE OF'REC%4RD [~ESIREt ~ (Enter Numbero# Cc3ptss) Search and Fee $10.00 Search and Fee $10.00 Certified Transcript a Per SPY Certified Copy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certfied Capy indudes all d the items d irrfarmaiion oocumng on the original seal d the towMaty deck. It indudes the names d the contracting parDes, their record d the marriage. residence at the time the license was issued, date and place d marriage as well as date and place d tarth d the bride and Boom. A Certified Capy may be needed where prod d parentage and certain other detailed infarmadian may be required such as: passports, vetexan's benefits , A Certified Transtxipt may be used as prod that a manage occurred. court proceedings, or settlement d an estate. BridefGro~ottttSpouse Name (as recorded on marriage license): Date of Birth: ~ ~ ~t.o.~t:»~..t,~., elc~zquez larnca~ ~~i)~i~q~~ ~~ If Previously Monied, State Name Used at that Time: Residence (at time of marriage): Fret trHdde !at ~y SYM &idelarciotrtlS~pcuse Name (as recorded on marriage license): Date of Birth: if Previously Married, State Name Used at that Time: Residence (at time of marriage): ~ trrrda. t..t sa. __ Marria~e;ln#orEltation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~. er ~~ lk iJVgj~i t-X Wq F- nc~Pr FG-115, ~i,1 ~~5 ~-~•••r ~-~.r-, , ~ Tew~ ar iowt a Purpose for which record is required: Date of Marriage or Period Covered by Search: ~,~ . G, sew rie.r \ ( ZC~ In what capacity are you acting?: What is your relationship to person whose record is requ~ed? ~,~~~~ (If salt, state'SELF'.) Srd- ra S ~...rdrinyp«iod~ (.e.ldd/rirr- If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant ' Date: AppGcaM's hone Number. ,, Q__S . - Na a of Applicant: _ Please print name a ~ Swhdt$ , s _,; ,ant: ,( ,; Address d Applicarrt: ~ ~ rr~~ C.yl ; .r 1-~ ~ ~ ~G Y ~ . N,l ~~ S~~ ZIP City Stet. ZAP DOH301 (9111) Pepe t of 2 ~i a NEW YORK STATE DEPARTMENT OF HEALTH Vitat Retards Section Application to TownlCity Clerk for Copy of Marriage Record TYPE OF'RECORi~ QE~RE D ijEnter Number of Copies) Search and Fee t610.0o Search and Fee $t o.oo Certified Transcript ^ Pef SPY Certified Copy per copy A Certified Transaipt is an abstract from the marriage record issued under the A Certified Capy includes all d the items d irriormation occumng on the original seal d the townlaty clerk. It includes the names d the contracting parties, their record d the marriage. residence at the 6me the fioense was issued, date and place d marriage as well as date and dace d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain other detailed infarrnatian may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as prod that a marriage occurred. court proceedings, or settlement d an estate. Bri' coo use Na a (as recorded on marriage license): Date of Birth: ~v s s~ ~ ~ ~~- ~ ~ ~~~ Ia+Y~afGaa~areriryy ~~~^~ ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): /' v'~c~e~5 l'~'~/ Fief tl~dda IJd CouA)' l~YN &idett3rocln/Spouse - Name (as recorded on marriage license): ~ ~ Date of Birth: ~ } faeCLv~~ l~~ ~ lC o l ~ ~ ~}~ r~ ~ ~` ~~~ ~ fa+w.rr~..aw.~:ar ~ ~ ~ ~ 2~ ~ 7 ~ ~ ~ . If Previously Married, State Name Used at that Time: Residence (at time of marriage): ess ~ ~ c~ ~ , ~v r•..f t~ rw weary ~++ Marriage lnforrttatiort Place Where Marriage License Was Issued: Place Where Martiage Was Performed: Marriage Certificate No.: Local Registration No.: (pCluW ~~ Wt\i~~t~ ~c(Z , C VJdb'~~~SS 1~ ~~ ~t~ ~ ~ppPl`~1e'~ ~ ` ~ ~a0"~N p~-1 iewr ar ioen a Purpose for which record is required: ~ Date of Marriage or Period Covered by Search: ~00~ d~- S O ~ ~ ~ (~~ b~ ~ 3~ In what capacity are you acting?: What is your relationship to person whose record is requved4 (..,~dd~myl 5 ~'~ (If self, state "SELF'.) >~ b ~ surd- ra: ,~, ~~ l~ A...~~ «~ ~ If attorney, give name and relationship of your client to person whose record is required: Sig of Applicant Date: Applicant's Phone Number. - ~ ~, ~~ ~ ~~ ~ 013 ~ '~ ~ -- ~ ~ ~. ~ v ~~ ~ N e of Applicant: Please print name and address where record is to be sent: a ~oX ~ S ~ Address of pplicant: ~~ ~ ~ O w ~0 ~ tw ~e ~ ~ i- r~- ~~~ YL ~~l ~~ S ~~ ~~ State ZIP City State ZIP DOH301 (8111) Pepe 1 of 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the of1•ice of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.cityder>tc.nyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. cor~o~ lug ~ i ~e z of 2 Of the United States, inOrder to/ono a moreperfeet Union, ertablisb Ju+'tice, insure domestic Tranquility, , provide far the common defence, ~; promoted>egeneral Welfare, andsecure ~, tb~ B/essrnps a~Liberty to ourselvesand ,~ t ~ 1'at+< tr, Flo ordain and establ%sb this (~ 'ti.;+ tin l~r/be C iitedStrtes n{,$mcti:%~ ~` ~. a, <; SIGNk'EURE a~ BEARER - S~~f ~PASSPQRT ~ .`~ j`~~ PASAPOR7E _ ~;y~,Bt~y~i P<USA~RGAN<<RtJ 4748114377USA,( ~... NEW YORK STATE DEPARTMENT OF HEALTH vital Records season Application to TownlCity Clerk for Copy of Marriage Record TYPE gF'REC4RD I~E~RE b +(Eryt~r Number Qt Ccf~es) Search and Cert~ed Transcript Fee t6t o.00 ^ Pef copy Search and Fee $t 0.00 Certified Copy per copy A Certified Transaipt is an abstract Fran the marriage reaxd issued under the A Certified Capy indudes all d the items d information axumng on the original seal d the townldty deck. It indudes the names d the axrtradmg parties, their recoM d fie marriage. residence ffi the time the license was issued, date and place d marriage as well as date and place d birth d the bride and grain. A Certified Copy may be needed where proof d parentage and axtain othe r detai{red irtfannatian may be requrced such as: passports, veteran's benefits , A Certified Transaipt may be used as prod thffi a manage occu-red. court prooeedmgs, or settlement d an estate. Brid oornl5pouse am/e~?(as/Irecorded on marriage license): VAT r~'O L- fiat tlridala ~~ ~ `~'~~ ~ tsat / ailhtYaars Date of Birth: f~-+a~ r.. ~..~oly.~ CO ~ ~ l If Previously Married, State Name Used at that Time: Residence (at time of marriage): v izi~`~S ,v First taHd~a !M ~' Stab &ideltra~cnti`Spar3se Name (as recorded on marriage license): ~~l-vU ~ Fear strser ~ ~ l~at t~ ~• Date of Birth: k•swarsar.a ~d~ % o ~7 If Previously Monied, State ame Used at that Time: Residence (at time of marriage): ~cJ~~ SS ~ ~( tea 8 __ __ Marriage>{rtforrtration Place Where Marriage License Was Issued: .~~ ~ U ~ ~ Place Where Marriage Was Perfom~ed: L~ ~ , p ~ l , (~ Marriage Certificate No.: la--"~N Local Registration No.: lewd o Te.n se for which record is required: Purp ~ ~_ C~~-~ Date of Marriage or Period Covered by Search: Il~risdawa I SsraM /tsar ~/ , In what capacity are you acting?: twat ~ Y~ relati°nsli~p to P~ MArose record is required? (If self, state "SEEP.) ~, ~~ ~ traardr br la~wvar~/ IMlarims9 If attorney, give name and relationship of your client to person whose record is required: Signature pplicant Date: Applicard's Phone Number. ~~c ~ ~ ~_- _._-_.__ Name f icant: _ ,,// Please print name and a rasa w~¢ '\ ~ i j Address d Applicarrtt ~~ F E B ~; 6~~ ~ i ~ ~ ~~ ?~~ - CU ~ T -~ City Scats ZIP City Stat. ZIP DOH301 (8It1) Pape t of 2 '~`"~' ~`rgrsa ~.~ ,'~.. r Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www,cityde->tinycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Glueens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (811 t I Pie 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to TotivnlCity Clerk for Copy of Marriage Record Vital Records Section - TYPE OF;REC4RD [~E~1RED (Ertf~er Number of Copies) Search and Fee $~ o•~ Certified Transcript Pef SPY A Certified Transaipt is an abstract from the marriage record is~ed under the seal d the townlaty deck. It indudes the names d the oorrtrading parties, Char residence at the time the license was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Trensaipt maybe used as proof that a manage occurred. Search and Fee $t o.oo Certfied Copy per copy A Certit"ied Capy inductee all d the items d information occuning on the original record d the marriage. A Certified Copy may be needed where proof d parentage and certain other detailed irrfarmation may be required such as: passports, veteran's benefits , court prooaerings, or settlement d an estate. $ridelGrootnlSpouse Name (as recorded on manage license): Date of Birth: (or opal 6.w el w.ayy F.~ ~, v ~ ~ ' I ~. as n.~. 1 I l . If Previously arried, State Name Used at that Time: Residence (at time of marriage): F~ ri<aan ~ I can ~"' Brideltroorlft/Spoutse Name (as recorded on marriage license): Date of Birth: (w(+'~D~ d a~ o/ ar~rirq~ Fasf ' ~ ~ flridd~ larf ~~ ~~ rl/ Z ~ 9'iAb ~ ~3 ~ .~ If Previously Monied, State Name Used at that Time: Residence (at time of marriage): r-a.r tea. ~ c~ ~ Ma~riage,fnforn~ation ;, Place Where Marriage License Was Issued: Place Where Marriage Was Performed: ~ Marriage Certificate No.: Local Registration No.: ~Icr In ,~;-5 ~~,-En<~ ~ ~ •e;sik~ ~~ Av ~ ~~~ Purpose for which record is required: r~~ Date of_ Martiage or Period { (( ~ (~ , ove ~ Search: f ~ In what capacity are you acting?: What is your relationship to person ' " ir ~aai~ I C ` ( .) SELF (If self, state ' Se- (~-. JAN 2 ~~,,,,r ~~ .- r~ ~Oc~( c ~- If attom ,give name and relationship of your client to person whose record is required: ~ r~° ~,~+~~ ~i ~ ~j ~ ~ ~ N ~9 QO ~ T ~ ~4' A ~S! v k ~ ~k ~~tl,~ Name of Applicant: U Address of Applicarttt ~ ~ ~ c ~l --I-_ I~S3~ ~~~4s~ X53 -- 3~ 'lease print name and address where record is to be sent: / ~ ~1a,~--~ f ~ ~ cJe..- ~ ~-~ -P~ I~-~pe.~ e~ I ~ cf- ~ `/ --T I~~ 33 Crfy star. ZIP DOH301 (8111) PeBe t o12 coy sir. ZIP NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Conv of Marriaae Record Search and ~ Fee $10.00 Search and ^ Fee $10.00 Certificaation per copy ~~~ ~~ Per cePY A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the Healtl~ Department, includes the names of occurring on the original record of the marriage. the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed 'information may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marriage oxurred. proceedings. or settlement of an estate. PLEASE PRINT OR TYPE Name (Prat) (Middle) (Last) Name Fast) (Middle) (Last) ~ ~ ~ r-~1 Bride ~C`-~--~ -~ ~~ ~-s~-- ~ ~ Groom '~ ~~ ~ Groom's Age Bride's Age or Date of ~O l ~ ~ ~ or Date of Birth ~~ Birth Residence (County) (State) Residence (County) (State) ~ ~ ~'~ ~ S G Groom ~ ~~f ~ Bride Date of Marriage ff Bnde Prevwusly or Period Covered / /' Married, State Name b Search ~ ` ~ ~ ~ ~.(~ Used at That Time ~~~L Place Where Place Where . Marri Was Dense Was Performed ~- ~ .•` '~~ For what purpose is information In what capacity are you acting? lMtat is your relationship to person whose record is requested? If self, state 'self.' If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant ~~ Address of Applicant Please print name and address where record is to be sent ~ f~ ~~ 1f _7r,,.~ ~~_, DOH-301 (3/s3) (pLFJ1SE SEE REV RSE SIDE) JAN2~~, ~ i ,~ A ~..~ i t ,, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records section Application to TownlCity Clerk for Copy of Marriage Record TYPE OF REG4RD t~E~RE D (Enter Number,of Copies) Search and Fee $t o.00 Search and Fee $10.00 Certified Transcript ~ Pef SPY Certified Copy ~ per copy A Certified Transcript is an abstract from itre manage record issued under the A Certified Capy inductee all d the items d information occunng on the arignal seal d the townlaty dark. It mdudes the names d the contracting parties, their record d the marriage. residence at the time the license was issued, date and place d manage as well as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain othe r detafied infamatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod thffi a marriage occurred. court proceedings, or settlement d an estate. 8rideltirtmmt5pouse Name (as recorded on marriage license): Date of Birth: (~ /~ Q.-Z ~n zGZ C Gi d/ ~ ~ ~ l ~ 1(1 fwry.ae r« er..riy~ ~j - (o - I ~(~ ~ . ~ M.» rsd~. / ( V,r / ~ If Previously Marred, State Name Used at that Time: Residence (at time of marriage): Fwad Ifld~a iaB CouAy lirN Britfr3lGroomtS~ouse Name (as recorded on marriage license): Date of Birth: 5~ ~~ ~k ~~~ ~ ~ ~-~5 ~ y - ads - I ~ ~~ ~N.» - ~r ,rr~. If Previously Married, State Name Used at that Time: Residence (at time of manage): ry.r Cdr. r,~ s~ __ _.__ Marriage InforrElation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: Wc~P i~~aS ~i.IIS U S W ~`~(" 't1~ ~i ~ls CJ 5 aew~a ~~ Tern a- iew~ a Purpose for which record is required: Date of Marriage or Period .~~. C5 p~,.~- ~~w~,`,t ~4J Covered by Search: Il~ei~doaa SMaii Tarr In what capacity are you acting?: What is your relationsh~ to person whose record is required? ~,~~~~ (If self, staff "SELF'.) _ s- /_ ~ ~ sraU rx - L- ~frrwah:gp.riadl pled/n'om') If attorney, give name and relationship of your client to person whose record is required: Signature d Applicant Date: Applicant's Phone Number. ~~~-. ~s - -~ ~ 5-y53 -8~3 1 Nam of Applicant: Please print name and address where record is to be sent: ZQ ~.~~ cG~ ~ .~ Z t'~ r- n n 20~ Address of Applicant: te ~5~~~-~~~ ~l ~~~P r 5-~-__ ~~- ~ J G 5 oy~1-1.1 Gl eve ~ 5~ ~~~ ~ I ~ ~ SDI ~ ~°e N`' ~~G61 City ~tatr ZIP City Sletr ZIP DOH301 (8111) Page 1 of 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881. to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.cityderknycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH301 (8111) Page 2 of 2 ~L~~NSE ~.: act ~~~ ~' y.~ cis u NEW YORK STATE DEPARTMENT OF HEALTH Yrtal Records Section Application to TotimlCity Clerk for Copy of Marriage Record TYPE OF RECORD [3E~iRE D (Entar Number of Copies) . Search and Fee $t 0.0o Search and Fee $10.00 Certified Transcript ^ Pef SPY Certfied Copy P~ SPY A Certified Transcript is an abs6ract tram the marriage record issued under the A Certified Copy indudes all d the items d information occumng on the orign~ seal d the tawn-city clerk. It indudes the names d the oattradarg parties, their record d the marriage. residence at the time the license was issued, date and place d marriage as weU as date and place d birth d the bride and groom. A Certified Copy may be needed where proof d parentage and certain other detailed irtfamatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage ooanred. court proceedings, or settlement d an estate. Hridel(3roomlSpcruse Name (as recorded on marriage license): ~ Date of Birth: I«wa r.. ernby~j ~ If Previously Married, State Name Used at that Time: _ Residence (at time of marriage): Fwd IIP~ddw lad ~Y SINw __. &tdelGroottrrl~ouse Name (as recorded on marriage license): Date of Birth: ,-~ ~ 6~1 b`~ ~ ~ pr,y,arr.. erriey~l 5 ~ ~ ar~,ra, C trrae~. t,.r J~ ryd ~~ y If Previously Ma ed, State Name Used at that Time: Residence (at time of arria e): F.d rFaar !.d 8~ Marriage tnforrtistion Place Where Marriage License Was Issued: Place Where Marriage Was Perf~'ed: Martiage Certificate No.: Local Registration No.: Purpose for which record is required: Date of Marriage or Period Covenad by Search: s~~ In what capacity are you acting?: What is you relationship to person whose record is requir~ed't ~,,,.~~~~ (If self, state'SELF'.) ~ L, ~J ~~ ~~v^~9 glad/myl If attorney, give name and relationship of your client to person whose record is required: Sign ~/°~ Applicant Date: ~ Applicant's Phone Number. Na a of Applicant: ,7 Please print name and address where record is to be sent: ~~~~~~~~~r ~~~ ~ ~.~ ~i s ~'~~,~ ~ s Address of Apglicattx , ~~s h ,~ ~ ~ 1 ~.~ ~' ~ z ~ z ~-r' City State ZIP City Sreto ZIP DOH~01 (8111) Pepe t of 2 r ..: r7 '`-"~ (....~a.~"~`""" ISSUED: 01-25-10 EXPIRES: ARK STATE ~D: y ~~ - S~(: ~ EYES: .. E: NDNE ~~_` R; B cuss o ~A ,~ r ':; r 02-03-18 euiweizer 1= NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vital Records Sedian :TYPE {~F'RECORD QE~#i~ED {Enter'Ntamber of Copies) Search and Fee $t 0.00 Certified Transcript Pef SPY A Certified Transaipt is an abstract from the maniage record issued under the seat d the townldty deck. It mdudes the names d the t~itraicting parties, their residence at the time the license was issued, date and place d manage as web as date and place d birth d the bride and Boom. A Certified Transaipt may be used as prod that a manage occurred. BridelGroorril5p4ttse Name (as recorded on marriage license): If Previously Married, State Name Used at that &idelGroornlSpousa Name (as taco on marriage license): ~~~ ~~ Search and ^ Fee $f o.00 Certified Copy per copy A Certified Capy indudes all d the items d infannation ooalmng an the anginal record d the maniage. A Certified Copy may be needed where prod d parentage and certain other detailed irrforma6an may be required such as: passports, veteran's benefits , court prooeetirigs, or settlement d an estate. ~-ICa~CIL~. Name Used at that Time: Marrisge;fn#om-ation Place Where Marriage License Was Issued: ~~~ g~ ~ ~ t~.~ 7e.,,a Purpose for which record is required: Place Where Marriage Was Performed: ~~ G~ Ma R Date of Birth: for oar at iw~ at arni~yy ~~ 1 iG I~~ Res (a~n `C of marriage): ll ~ 1~.~~ N Y Date of Birth: (a-ayorat6wMe<a~ Residerxe (at time of marriage): I \l ~~~ lv I cow soN. triage Certificate No.: Local Registration No.: ~N ~~ In what capacity are you acting?: v What is your relationship to person whose record is required? (lf~; ~ ELF'.) If attorney, give name and relationship of your client to person whose record is required: Name of Applicant: ~ ~~ ~ Please 'nt name and address where i ~l c~-'G ~ ~' 0 8 ~ uhG ~ T ss d Ap icartt: o ~~ I ~ ~`~~~ r ~~ x. G~ I I ~ ~~ IBC U~ ~" ~ ~ ,...,:~ UG Date of Marriage or Period Covered by Search: G~~I~ ir.ieeirryrl sran ioc IAr+..drirgpriaaP (w./dd/Aril to be sent: ~1G1'~ I ~~n~~~~ ~Y ~~~~~ ~h~~-~ b~'~ City State Z1P City State ZIP DOH.901 (8/11) Page 1 of 2 Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section .~:. Search and Fee $10.00 ~ i ifi Search and ~ Fee $10.00 Certified Copy ~ p~ spy cat on Cert Per coPY A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the Heap Department, includes the names of oocumng on the original record of the marriage. the contracting parties, their residence at the time the Immense was issued as yell as date and place of girth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed information may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marriage occurred. proceedings. or settlement of an estate. :>~ `f>> '':k::. PLEASE PRINT OR TYPE Name (Prat) (Middle) (L:ast) Name (First) (Middle) (Last) i of Groom V t°CC n l~- hr- . ~(~~d:-rn P of ~ ~Q /~L Bride `7~"G~L ~iC//1cC Groom's Age Bride's Age or Date of Birth D~~ o ~ or Date of Birth D~ ~ z i9 8' Residence ( unty (State) Residence (County) (State) of broom ~Gl~ ~h ~'S,S' of Bride C~ PSS ~ V Date of Marriage or Period Covered TT~~ ff Bride Previousty Married, State Name ~' b Search V 5 ~ 9 2 ()/ Z Z-a.. Used at That Time Y Place Where r / Issued W ~~.l~Ja-I7 ~~ 1 ~ ~ / /~S' Place Where Marri Was Performed l ~- lam/ D ' Q C~ For what purpose is information required? What is your relationship to person whose record is request ff self P / t aSS t In what capa/c~ ity are you acting? If attorney: Name and relationship of your client to persons t ~ o / L ~~ image record is required. DOH-301 (3/9:i) (PLEASE SEE REVERSE SIDE) NEW YQRK STATE DEPARTMENT OF HEALTH Yrta- Records Section Application to Tot,ifnlCity Clerk for Copy of Marriage Record TYPE OF "RECORD ~L3ES}RE __ _ _ _ __ © ~Ent+er Number of Cc:piss) Search and Fee $t o.00 Certified Transcript ^ Per SPY Search and Fee $t 0.00 Certfied Copy ~ per copy A Certified Transcript is an abstract from itre marriage record issued under the A Certified Copy includes all of the items of information occurring on the original seal of the townlaty deck. It includes the names of the oorraacling parties, their record of the marriage. residence at the time the lioerrae was issued, date and place d manage as weN es date and place of birth of the (aide and groom. A Certified Capy may be needed where proof of parentage and certain ache r detailed irrfarrrratian may be required such as: passpartc, veteran's benefits , A Certified Transcript may be used ffi proof that a manage occurred. court proceedings, a settlement of an estate. Bride~(3roomlSpouse Name (as/~reco~rded on marriage li~ce/n~se): / ~ ~~^4-~^" ,~' ' ` t C1~lA~ ~CZ ~0~~ tR.r tea. ~. trer t+r.^. Date of Birth: la<~a,ra.. orw.rl~ 1o~~~f ~~ If Previously Married, State Name Used at that Time: Residence (at time f marriage): r ~ ' - ~ Firsf Y~ lpf ~ ~~ N pu 4r 'c~ J~ - , v &idetl~rc-o~ntSpcuse Name (as recorded on marriage license): t'~Q ~~ f Date of Birth: /1/], c ss~ rte. ~ ~~ ~j _~~ 8a If Previously Married, State Name Used at that Time: Residence (at time of manage): r.r reu. wt star. Marriage lnforretatott Placel Where Marriage License Was I~s~s~u~e+d(:' Pla/ce WhJ-ere Marriage Was Perfojm_red: Marriage Certificate No.: Local Registration No.: rewi x rowi « Purpose for which record is required: ~„~ •b~v...~.~,~~}-S p_ ~~ ~" ~ Date of Marriage or Period Covered by Search: ~~ ~ ~ „' '_ oc~__ Mni~dena doer In what capacity are you acting?: 1`0 ~, ~ What is your relationship to person whose record is requaed9 (If salt, state "SEEP.) ~:¢.-~ ~~~~~ sad, br ~arrdiryp~rie~ Iwwldd/~- If attorney, give name and relationship of your client to person whose record is required: Signature of Applica Date: Applicant's Phone Number. Name of pplicant: Please print name and address where record is to be sent: Address of Applicant: ~1' ~fe ZIP City Stab ZIP DOH~01 (9111) Page 1 of 2 :W YORK ST ~c~; rya ash. ,~,~ i ~.t a. rss~: o6-as-n~ _,_~~_ ,~:~, _ ~ ;~,: F~~ ^~ o-~arg , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and ^ Fee $10.00 Certification P~ cepy 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 t~rth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and ~ , /~ Fee $10.00 Certified Copy U Per coPY A Certified Transcript includes all of the items of information oxurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings. or settlement of an estate. PLEASE PRINT OR TYPE Name (Prat) (Middle) (Last) Name First) (Middle) ( t) °~ ~s v ~ ~~ ~ Bride R>srf~ ~~~ C~i~~i~ Groom ~/~- /~~- ~ /~ Groom's Age Bride's Age or Date of ~ ~ y ,95~ ~ s ~ ~ / 9s3 Birth Residence (County) (State) , / Residence (County) (State.) / (~ Gn~orn ~/~ //U ~~s ~~ ~~S /V Bnde l/~ ~~i~~~ f ~~ s /~/ ./ Date of Marriage ~ ff Bride Previously ' / ,~J ~/ or Period Covered S Married. State Name ~~~ST~/v ~/~/~ / /~H~ Search / o~ `'I /~1 ~ l used at That rime Place Where / Place Where License Was~~ ~ti19~ F1~11-5 /Y `J' ~W ~ Gt~f~-Pj~i/i/J` E~ ~f~G~s -~` Issued For what purpose is information required? What is your relationship ro person whose record is requested? ~~ / V ~/~ S ~ ~~ 6 ~ If self. state "self." j E- L In what capacity are you acting? If attorney: Name and relationship of your client ro persons whose marriage record is required. ,. ; Oats ~ 1L ~~ Please print name and address where record is ro be sent. ~ y ~ti~y~/a~-s ~~~r- ~ ~~ ~ ~~ ~~ > -3of (sue) Application to Town/City Clerk for Coav of Marriage Record /iG( ~~~~G (PLEASE SEE REVERSE SIDE) Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present Apply to: Certification Unit Vital Records Section P.O. Box 2602 Albany, NY 12220-2602 * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers Albany: City Clerk, City Hall, Albany, NY 12207 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 Yonkers: City Clerk City Hall Yonkers, NY 10701 2. License Issued in New York City Apply to the Borough office of the New York City Clerk that issued the marriage license. The location of these offices follows: Manhattan - Municipal Building, New York, NY 10007 Brooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 1908-1913 are on file with the Manhattan office) 1780 Grand Concourse, New York, NY 10457 Queens - (Records prior to 1898 are on file with the New York State Department of Health) 120-55 Queens Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1898 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Copy of Marriage Record Search and ^ Fee $10.00 Certification p~ cePy A Certification, an abstract from the marriage record issued under the seal of the Healtl~ 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 Certfication may be used as proof that a marriage occurred. Search and ~ Fee $10.00 Certified Copy per cePY A Certified Transcript includes all of the items of information oxurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings. or settlement of an Mate. .,;~: 1:. PLEASE PRINT OR TYPE (La st) Name (Prat) (Middle) Name (Fa'st) (Middle) (Last) n ~,, ~ TCi~n ~+~al-`~C'c G Bride ~-~~/i /~~ ~z~.1~ room Groom's Age or Date of ~ ~! ~ ~ `~ ~~q Bride's Age or Date of O g / ~ ~ ~ ~ ~y Birth Birth Residence (County) (State) Residence (County) (State) of ~ L~ Groom I~v~S~ ~ Tx ~ `~~ Bride ~Z~P_GtX, Date of Marriage ff Bride Previously or Period Covered Married, State Name search C~ /C~~. ~ ao~3 used at rnat rme Place where /~f license was '" ' E' ! " y ~ ` ~' Place Where dw~ ~oi,a't o-f ~i7 KQ4~J~' L°., Pe m ~ 1 - , -1 V~ Issues rf ort r~ For what purpose is information required? What is your relationship to person whose record is requested? nn g self, state "self.' (~ ~~~~~~ 'r~~/ fir ,%ri~/~~~-~ ~.~'1'" In what capacity are yo acting? tl attorney: Name and relationship of your client to persons 1 whose marriage recerd is required. ~ /~ ~ Signature of Applican Date ~ / ~ n ~' ~ C aL Address of App icant Please print name and address where record is to be sent ~~~;~ 3 ~nonc~ccc ~,LK ~P ~ ~J;.~~;n9e.-5~e~lls, NY 1a.5~b DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) A ., W RK STATE x .I a~~ ~~ ~ t -~ ~_ z f?~~ .V ~ u Pig _ ,~ ~ , ~ ~-~~ + ,. ~t4 : e~.ss.as ors: e~-oe-u ~,,r,,, NEW YORK STATE DEPARTMENT OF HEALTH Yrtaf Records Sedian Application to Totllm-City Clerk for Copy of Marriage Record TYPE ©f= RECORfl QE~RE © (Enter dumber of Codes). Search and ee Si o.00 Search and ^ Fee $10.00 Certrfied Transcript Pef ~Py Certfied Copy per copy A Certified Transcript is an abstract from tl1e marriage record issued under the A Certified Copy includes all of the items of information occumng on the anginal seat of the townldty clerk. It includes the names d the oontrading parties, their record of the marriage. residence at the time the license was issued, date and place d manage as well as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other detailed irrfarmatian may be required such as: passports, veteran's benefits , A Certfied Transcript may be used as proof that a manage occurred. court proasedmgs, or settlement of an estate. Bride{(3roorntSQfluse Name (as recorded on marriage license): Date of Birth: /ar epef tAee of erniey~J r ~ v t,.r ~~'E.C trraw~. 6 3 If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~'~ ~ ~ (11~~CI ~~(1-~ jRp`~'~ t=aer tom. tr co~rr sr~. N. i &idelGr~mi'S~oerse Name (as recorded on marriage license): Date of Birth: prayratGnoterrieyy t~Yd/o !at ~ trtt~ lm-. If Previously arced, State Name Used at that Time: Reside at time of ma 'age): ~~ ~~s ~o ~`-~~ ~. ~ ~ ~ ate. Marriage: to#orrrrston Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: Te!wi or C ~ P iewr a Purpose for whi h record is required: ~ Date of Marriage or Period Covered by Search: . IbrieAoaa V SraA her d? h v In what capacity are you acting?: ose retard is requ e What is your relationship to person w ~,,,~~~~ (If seN, state "SEEP.) s..en to: (rfa..arsyPwinaP (ww/dd/m71 If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicant's Phone Number. s ~ ~~~ ~~f Name of Applican . Please print name and address where record is to be sent: r~~~si ~~,~r-- ~~ is~~,~' Address of Applicant: ~G~~/ ~~ST~/~..,~.~ 6~~ , City State ZIP City StaN ZIP DOH,901 telll) Pape 1 of 2 Appt~~a#i~n of Townltrity Clerk V+tEa YReco ~ TSec~n EPARTMENT OF HEALTH #(~~" LE~~1 O~ t~~I~~fC~E~~ ~~~'iO~d ~er~tifiC~t`rOi'r 1____l Fee ~i0.00 ~y ~ Fee $10.00 L_.l per copy P~ SPY A Certification, an abstract from the marriage record issued under the seal. of the Heaitt- fJepartment, incomes the names of the contracting parties. shsir residence at +~rs time the I'icense was issued as well as date end pl~e of birth of the bride and groom. A C,ertificati9n may be used as proof that a marriage occurred. A C.eriified Transcript indtrdes ~ of the items of information oxtrrring on the original record of tiffs - A Certified Transcript may be needed where proof of parentage and cerEain other detailed information may be required such as: passports, veiaran's bersfits, court proceedings, or settlement of ~ estate. Nn •. {7. PLEASE PRINT OR TYPE Name (First) (Middiej (tasq Name (Pest) (Middiej (Casrl I G om (fir' Gl i ~m Lacv~ence.. ~' e~riae IUCZnc ~'L ~%uR ~N~ Groom's Age ~~~ ofi 5 j2~ j,~Jo_ ~li~ Bride's Age Q- f~ taof ~/a CJ ~~s~- Old Residence (County) (state) ~ - 1v acv ~°i X r CO ~ ~d O/a Residence ~ " - (nCounty) , I (State) Co B ~ ~ ~°X ~ . . ~, r ride 7un IXO N ~~e of Morrie e U c~ anb (-(8 ? or vered If Bride Previousiy Married. State Name r 1 ~ / ~~~ /'~Nz~ r c ~) /V L Search - .. Used at That Time ~ Pi~:e Where , n ers A l S P~ v~,ere ~--1 om e o-~' $~i des enfs ~~ W~ iUety V ~ k ~ a 59'o ~ p ~ ~; ss Kd . ~~ s . . For vrhat purpose ~ information required? 1iVh~ is your r~ationetrip ~ person whose record ie requesthd? ~ "r -iL - Lo s~ ~rria .~ if salt. stsoe •se~.• S ~l ~ C°r-~i~'~" 2~ In-what capacity. are you acting? It aaomey: Name and relationship of your client to Persons S ~, ~ whose marriage retard ~ required. Si a of Applicant Date ~ g t3 Address of Applicant (~ $o deco-s Loo ~ • ~• Please print name and addre~ where record is to be sent. I l,vl'LC~ ct.m ~ . F~~C~[~R ~i o (~ancNo , ~ ~V~cJ I1'121Gi CO (~'o Pecos Loop S, ~ . $ ~ l 02 ~- {~i o i~ncN o ~ lv~J ~2X~GO g7(a ~oH-s~~ (s,~) (PLEASE SEE REVERSE SIDE) N~lic, my name is :Niiliam ~. Finc!:eT and my wife and I are regc;esfiing a copy of our „:Triage license. We have poked everywhere aril cannot fir-d our original rr-arr ia~e iiC;eriSe. i 1ie copy will die used in part as proof of our marital sfiatus far our retirement dacumentafiion, Beiaw is a copy of ouT government issued phata ID's: ~.x~..m __ _~~.._~ N ~'W M 8 X i CO =r~r .:+~,;~„~,---n__. DRIVER'S i iCENSE ~ uex~e -i .037398869 issued OBJ21l2o10 ouot elm, 08/26!1950 Exw~s 08/Z6J24'i8 F1fii+Ci~iEH l!ll~Li~R~! bD0 PEt70S LOOP SF :;~' ~ ~ ~~-~ ,~-, :~ SEX M NliC.HT S'1 t a~r:,,a.i....-.. CLASS ~ Ell~DOits9aEti~!'>~'':9~it$ iiElfTRICTId18 B z ~. G-. Y1 M. G ,/6 t L V "wo" 'MsP' ^s+r' ^4P''_ _ <. ,ter DRIVER'S LICENSE ticsrne a 0:i%:SCJbti%% ISSt)ED t7t>f11l1N1U riste ^t 9+!!h f1~f~S2t14F~ EYaiaES 07f2~2~Q1$ -~'~ ~ ~" FIPlCNER . ~~ ~ ~ ~ r z _NANCY E . '~- "~ R-O RANCMa. iVi! t~4A~ -3* WERiHC 440 EYES 9LW ~`" - -~P~-c ~-.~-- CLASS •D ~i!MMiORBEM negrpenr:J.-~ ~ ldOTARY Plr3LIG - STATE (?F iJEYc' M ICC My ~am~issiwyaxgre®: ~,~ .~~, :~~` ~~~~~~ ~... __ .~ ~o0 ~o ~~G!I/!~1~ __ `nom ~~~. C~'~ ~V /~ 7a~~ ~~2/ttic~ ~~ ; ,r0 R i a c(~~ i i9 ~?~ L~J~c~,., ~/' lYl~ Ca,~a~~ -~~~~ __ ____ are _ ~ ~ _ _ _ _. ='• :'= MY COMMISSION ~ EE17~S7 __ ___ __ __- _. _ fJtPIR~8 March 1.2018 ~.~`~~, ~., /)-- l2U /CJ 2l7v) o~ m Ctc~ ~Yl~/Lvu~ ~9 G~ ~ o~ Y~ct/vua~e .~fiz,L<~~.~~ ~~ ~--~. ~~ ~~-a ~~ NEW YQRK STATE DEPARTMENT OF HEALTH Yrtal Records Sedian Application to TownlCity Clerk for Copy of Marriage Record TYPE t~F REC4RD ~E~Fi£ ~ (Enter l+l~mber of Co{~iQS) Search and Fee $i o.0o Search and Fee $10.00 Certified Transcript ^ Pef SPY Certfied Copy per copy A Certified Transaipt is an abstract from the marriage record issued under the A Certified Copy indudes all d the items d irdormation occurring on the arigirral seal d the townlaty dark. It mdudes the names d ffie contracting parties, their record d the marriage. residence at the time the license was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain other detailred information may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof that a marriage occurred. court proceedings, tx settlanent d an estate. 8ridelt3room15pouse Name (as recorded on marriage license): Date of Birth: ~oannQ i~a/iGY LavlQ >~ ~ t,.r arrr<tti... ~~~`•~•~, ~° I ~ o f ~ 48 `f If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fist I~d~s !~ ~Y ter BridelGrcromtSpause Name (as recorded on marriage license): spy r,~d~'1 ~~s ~~ Date of Birth: ~•.,. ~».t ~~23 i9r3 If Previously Married, State Name Used at that Time: Residence (at time of marriage): t3r.t wear t.~r ~+ Marriage<lrr#orrnation .. Place Where Marriage License Was Issued: U1It~I~i~S {al/J j~U-1"cl'tPS~ J Place Where Marriage Was Perforated: w~~~!~Fi~fa~l1 j~u~[-~teSj Marriage Certificate No.: ~~°"'r Local Registration No.: pr~«~l Te.„ e, Tows a Purpose for which record is required: ~~~~~~ Date of Marriage or Period Covered by Search: WrtwOana Ssrroi fissr In what capacity are you acting?: what is yow reletiorrship to person whose record is required? (If self, state "SEEP.) ,~~~~ N..,~dd~~ ss.eu ~ lean~f (ww~eN/~ If attorney, give name and relationship of your client to person whose record is required: Signature d Date: UI ~ I v 2013 Applicant's Phone Number. I ' J. ~" ~ 1 & 7°6 ~i 37'0 Name of Applicant: ~~ a,'7 t'l~' LEI ~ Please print name and address where record is to be sent: Address of Applicant: YV ~ 1~1 N I2 5 ~ City Stele Z1P City Stets Z1P DOH~01 (8111) Pepe 1 of 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/vita! records/merriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: wNrwrdtyderfcnycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) {Records prior to 1898 are on fife with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOFI,901 (8111) ('ape 2 of 2 ~~~ ~~~~~;~~r~ ,,. ,,... ~ .w,~ it { _: b ' lie '{ z;' lL1ANNAMAPIA ' , . , tOANNA INARiA 3. I6ay>:vewr/National#y,;. +E/1/1M NIKH /HELLENIC 4. ~uAo/Sex: F 5. HN. y@vvr)arlS/Date of birth: 20 Jul 84 6. TonoS ycw~arlS: ~ AOHNA Place of birth: GRC ATHINA 7. HN. tKboa~S/Iss. date: 18 May 11 6. HN. Afj2;~S/Date of expiry: 17 May 16 9. EKB. ApX~j/lss. office: A.E.A./~.A.- N.P.C. 10.'YyioSlHeight: 1,64 P<GRCLOULA«IOANNA<MARIA«««««««««« AH39246423GRC8407203 F 1605170«««««««00 ~ ~.~~ ~~ , r .~~~ ~~l ~ ----- ------- t-~-~---,--~----- ___. ~-- __ -- _--- --- ~s All-purpose Acknowledgment L ~ fie. STATEOF____~V~~'1,~I~~ /, /-~ ,COUNTY OF On ~~QUI L~-a-i/4 ~ V ` ~~_ before me, the undersigned, a Notary Public in and for said State, perso ally appeared (!Ylav~YlG ~b~(s~c ~.~ -~ C personally known to me -OR- roved to me on the basis of satisfactory evidence/ to be the person(s) whose name(s) is/are subscribed to the ithin instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hary~ and official seal. Name My com fission ~cp~ire~! ~ /~ ~o r lip ~~ ~~-e.v NEL7494 (2-06 91916) (Seal) ~. „ ~i~, . ~. '3TA1'E OF tN , ,:.: MY t30MMISSIQN EkPIRES.J14Nt1MX 1:15 ~ a~~ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ^ Fee $10.00 Certification p~ cePy A Certfication, an abstract irom the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at tl~e time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and ^ Fee $10.00 Certified Copy per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such ss: passports, veteran's benefits. court proceedings. or settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) ~ Groom Y ~ CI Y 0 S'e- of n Bride 11~ ~ 11 'el Groom's Age or Date of ~' 2') ~s Bride's Age or Date ~ I I ~ Oj ~ g3 Birth Birth Residence (County) (State) Residence (County) (State) °~ Groom ~ Li ~ S S ~ Bnde ~ -2SS C.o Date of Marriage ff Bride Previously or Period Covered ~ p ~ ~ ~ Z Married, State Name b Search Used at That Time Place where Incense was wq~~i n~-e+~s ~ 1 I S ~ N`~I Places Where ~~ ffi T~-2 a c ~ -'~ ~ Iv`-~ For what purpose is information required? I~PUJ ~yt~~ V ~Irl hn A. v Y 1,2 01 1r~~-- Inwhat capacity are you acting? ~ L~ What is your relationship to person whose record is requested? If self. state 'self." ~~ ff attorney: Name and relationship of your client to persons whose marriage record is required. Address of 8ppl~ant V 1 q~l-~"`f''' ~p ~r~ v-~ i r~5~,~-s F~a 1 J 5~ 0~ Y/ Zsq o DOH-301 (3/~i) (PLEASE SEE REVERSE SIDE) ,.,NEW YORK STATE. ~. DRNEI~~-~.ICENSE ID: 855 X431 000 CLASS D ~: ,AiN,e ~ ,M,,,, TOR NOR NJGE TtY 12590 09-1 ~ ,' SP~f: F #+~: E NONE ~ '^r '~' iSSUED:10-31-12 EXPIRES. 09-13-14 ~oiwuswc ''.s. of b.' ' y~_ ..~ rY'' K - '• ~ , .a. `,.,~~ _.. , 1 NEW YORK STATE DEPARTMENT OF HEALTH Application to TotimlCity Clerk for Copy of Marriage Record vital Records section TYPE 4F' R~CORfl t~E~#RE D (Ertfter Number of Copies) Search and Fee $10.00 Certified Transcri t per cop Search and Fee $10.00 C rtifi d C ~ y p e e opy per copy A Certified Transcript is an abstract from the manage record issued under the A Certified Copy includes all d the items d information ocarrong on the a-iginat seal d the townlaty clerk. It dudes the names d the controlling parties, their record d the marriage. residence at the time the license was issued, date and place d marriage as well as date and place d birth d the bride and Boom. A Certified Copy may be needed where prod d parentage and certain other detatied irrformaticn may be requrced such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage occurred. . court proceerings, a settlement d an estate. i3rid ro~oml rJSe Name (as recorded on marriage license): Date of Birth: T05Ep~~ .ANii-tdn/y C~2T~~,_ ra.a~atfrotarrLy~J rar ~ ~ arrrr~ -) If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fnt arr. !at Com(r Steer id roomtSpouse me (as recorded on marriage license): Date of Birth: ~i~.~/i///E ~DZig~~ ~ r~~~y~ (a+S'~e~6waotweniaer If Previously Monied, State Name Used at that Time: Residence (at time of maniage): ~ rdrlr. it sde. Marriage tnfwrtiat~otr Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.. Local Registration No.: Tewn e+r iqm a Purpose for whii;h record is required: Date of Marriage or Period I G~ ~C~ r /t: ~/"~v, ~ Y Covered by Search: ~/ M~ri~d oa ar ~ ~"°"`°a` In what capacity are you acting?: What is o y ur relationship to person whose recall is requved9 D ~~ ~~ (Ifselt, state'SELF'.) S ~ L ~' seeed- eer If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicarrt's Phone Number. / Na a of Applicant: Please print name and address where record is to be sent: Address of Applicant: 2 ~i~ 7~ ~j~/J~ ~~ City' State ZIP Cdy Stab ZIP wnavi rWn1 rape i of z _~, a ~:;; . ~~~ , ~. 1~ {J' ~Y! Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to. present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.cityderknyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on fife with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH301 (8111) Pape 2 of 2 ~ NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk for Conv of Marriage Record Search and Fee $10.00 Search and I / I Fee $10.00 Certfication ~ p~ spy Certified Copy ~~~,,,JJJ per coPY A Cerffication, an abstract from the marriage record issued A Certified Transcript includes all of the items of information ---~_ ~ psi ~ tl,e Health Department, includes the names of occurring on the original record of the marriage. • .~ _ ,:_..se __ __ __ _ nrnof of --ANEW y RK STATE. ~r DRTVEI~t:IdCENSE f'D; 6Q9.371 657 CLASS D a 3; ONdRq FKAYLq,Iq ^p I(p,1~ ~MS7A~E ia,. i 44 {NGE ~A~-1 NY 12590 09-0$:@g :`'"' SEX: F EYES''~!q }iT '5-09 . E. NONE ~~fL~.,~t.~~t, a NONE «k , ~~~ ISSUED: 07-12-12 EXPIgES 09.05-18 gpgp~a . iUe'Sted~ Sent. T ~25~b NEW YORK STATE DEPARTMENT OF HEALTH Application to TotilmlCity Clerk for Copy of Marriage Record veal Records Section - - -- TYPf OF RECQR© QERED (Enter dumber of Codes) Search and ^ Fee $10.00 Certrfied Transcript Pef SPY A Certified Transaipt is an abstrad from the maniage record issued under the seal d the town~aty dark. It indudes the names d the corrtracting parties, their residence at the time the lioarse was issued, date and place d manage as weN as date and place d birth d the bride old groom. A Certified Tralsaipt may be used as prod that a manage occurred. Search and ® Fee$1o.00 Certfied Copy per copy A Certified Capy indudes afi d the items d information occumng on the original record d the maniage. A Catified Capy may be needed where proof d parentage and certain other detailed irdamatian may be requrded such as: passports, veteran's benefits , court proceedings, a settlement d an estate. i3rid Groom/spouse Name as recorded on marriage license): Date of Birth: ~. ~ ~ arm nr.n. 7/~ ~ If Pre~sly Married, State Name Used at that Time: Residence (at time of marriage): -/l G--~a n ~ dl~..l ~ ~ ~ ~~a~ ~-~~ mss ,~ c~ . .~.... ~~ couMr sa. &id Gr ut:e Name (as recorded on marriage license): , ~ p ~f- Date of Birth: Fr>rf Ilyda~ ~ ` !nt ailb Nr ~/o~ ~ ,S 1` If Previously Monied, State Name Used at that Time: Residence (at time of marriage): ~u,.~-~j2.~'S N - _ _. I~larriage>Imforriaation Place Where Marriage License Was Issued: /P~la~ce Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: G(,/Yl~ ~~i-2~ ~l/Q~~/Y~~%/'S .~~1~~e.S~ ~a°~°V F~.~l Tew~ ar Toan a Purpose for which record is required: Date of Marriage or Period re~dYlG~IQ ~( ~dGu6~ler~~J ~ Ode c~r`e~~ ~Gc~n'12 coveredbYSearch: ~~ /a 3v ~9 In what capacity are you acting?: What is,,youpr relationship to person whose record is requrded? ~ ~~ s..eu br ~r,..ar~:gpwiodP Nw/dd/l7ril If attorney, give n~n1e and relationship of your client to person whose record is required: ~ l/a ~~~~~//j ~ 7 1~~13 ~~~~i~ 6~~r^~~t~i~ ~~ Address of Applicant: a ~c/ ~ n.d~ccl at1 d ~ ~L'~ 'lease prints name and address where record is to be sent: ~ ~~ 1~~-u-~oa q° ~~ L'2 N~hu~, n/% ~' State ZIP ~ Cify Stator DP r1f)H Aff1 IAlt11 Pwea t of 2 Where to Appiy for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present (630.00 per copy) If a state issued copy is required or you are not certain in which city- or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in Nsw York City Contact the office of the New York City Clerk for information 'rf the marriage license was issued in any of the five boroughs of New York City: www.cityderknycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (8111) Page 2 of 2 .NEW Y,~RK ST 6~'X sF EYES < E NDNE ^r.~ '~~ I ISSl1E~ 09.2fY11 EXPIRES: 07-2fS-20 ~zvavKVao DR,IVE~~.,ICENSE ~,. ID~:13~$~9y~Q~7 832 CLASS D Oy~r MLI lL1 N~ _ ~~ ~~ ~' AW ,~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Copy of Marriage Record Search and ^ Fee $10.00 Certification par cepy A Certification, an absfract 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 txide and groom. A Certification may be used as proof that a marriage occurred. Search and ^ Fee $10.00 Certified COQ per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veten3n's benefits, court proceedings, or settlement of an estate. <~ PLEASE PRINT OR TYPE Name (Prat) (Middle) (Last) Name (First) (Middle) /Last /~ ~ / ~ ~ of T h~•-~-c~ ~'7 . G•~AG,Jfi~ .. of " Bride ~b/1~T1~ Groom Groom's Age Bride's Age or Date of ~~ ~ ~ / or Date of //r~t~ / Birth Birth Residence (County) (State) Residence (County) (State) ~~~~ ~ ~ ~~,~~~~ ~y Groom Date of Marriage ff Bnde Prevwusly or Period Covered /'Yo /. ! /~ ~' ~ Married. State Name b Search 7 Used at That Time e Was luiq~Qir~G~/1.o3 ~~ Li ~~ Marriage Was ~;j~Ly ~"~~~ i~ ~f~v/LC~ cens Issued Perfornted o c./GI~.C-~~~i~ For what purpose is information required? What is your relationship to person whose record is requested? ~~ ~ ' ' If self, state 'self." ~_ F ~ ip ~ /~o /~ /Yi9/7 In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. signature of Applicant Date / /~ ~3 Address of Applicant Please print name and address where record is to be sent. ~l4GG~ ~/4s7~ / b v~f~i~~~~..1r~~ ~ X02 Ca0 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) ~NEW~.ORK ST DRIVER LICENSE ID: 638 p57 557 CLASS "D ~j , ,tM1GAL~N ~ ~ a oy- SIX; F EYES. '5-06 E, ''.NONE ~: R' B ~ , a~+-~'~°~~+ "~"~ ISSUED'. 01-0312 cXPfRES. 01-04-20 aoeviceaco June 28, 2013 Dear Town Clerk: I am requesting a certified copy of my marriage license for the purpose of renewing my Florida Driver's License. I was married on 05/30/1982 at St Mary's Church the village of Wappingers Falls. My maiden name is Deborah Jean Santillo. The groom's name was Brian John Ross. I was divorced from Brian Ross in 1990 and returned to using my maiden name, Santillo. On 11/30/2002, I married Lonnie Eash in Venice, Florida. I have enclosed a check for $10.00 as mentioned on your website, the completed Application for a Copy of the Marriage Record and a government issued photo ID, my Florida Driver's License. Please, send the certified copy to: Deborah Eash 7706 Monarch Hill Way Apollo Beach, FL 33572 If you need further information, you may email me at kentobe(u~verizon.net or call me at 813-482-1391. Sinc Deborah J. Eash it -_~ _ ~, -p- JUl_~i3 ~v ~ i, , C r"ti , AFFIDAVIT STATE OF _ ~ I O'~ l ~1 ~ CO UNTY OF . ~ Before me personauy appeared ~,)eb~ Vt~. r 1 ~ E ~ ~ who says that helshe executed the above in trument of his or her own free will and accord, with full knowledge ocf~fhe purpose therefore. Sworn and subscribed in my presence this ~ O ~L day of ~f.(,YI C ., . 20 ~ 3 . My Commission expires on ,~(~ rC~l ~ ~J~ , 20 ~ 1_. sonally Known -- or - Produced Identification ' Notary Public: ~ lj<~ ;%~-~~ O Type of identification produced: Effective; 819!2001 Pursuant to Original -Employing Agency Approved 2!7(2002 Sections 943.13 (4}, (5}, and (7}, F.S., "' CATHIEEN J. BIGDEU . = MY COMMISSION N DD 940567 = EXPIRES: March 13, 2014 Bonded Thru Notary Public Underwriters NE~i- 1"C~I:h ST_-1TE DEP_-1kTTIENT C-F HE_~LTH ~~~llCiltlOi] to TO~Z"ll~~~lr1' ~~~el'~ `~'rfal kecords Sutton For Copy- of marriage Record TYPE OF RECORD DESIRED Check one Search v-d Fee b1U ilU Search and Fee $lU UU c:'e-t-ttcat-on ~ Per c~q~~~ C'ert-iicahon ~ Per cop}' .~ C'ertdicat-ou, v- abstract from the mvr-a_~e record -s~ued t-nder _~ <'e-tdied Trv-script mduiles all of the rte-us of u-forn-ahon the seal of the Health Depvfiuent, includes the uvues of tl-e occn-rn-g on the wt,u-al recwd oftl-e marna~e conhachn~, pvt-es, their residence at the ttn-e the I-cense „-as issued as «•ell as date v-il place of both of the bride vul ,room ~ C'c~-tifleil Tra--scrtpt n-a}• be neeifeil „i-ere proof of p:u entae v-il ce-tam other detailed tnfor-uatton ma~• lx requueil such as passports. _~ C'e-t-tication mar be used as proof that a marr-ase occurred. ~.•eterv-'s be--etits. court proceedn-as, or seftle-ne--t of :u- estate. PLEASE C'ODIPLETE FOR]\I AND REMIT FEE LT F ~ CF LR TUT f tR Tti~F _. Name (Fast) (1\Itddle) (Last) N:une (Fu tI 11\Ilddle) (Lai ) ~ +=~f ~oN N ~'~ ~ °~ ~OSS U t-~t ~f ~~H ~E'd'N' sA~--~- ~ ~ Tl Ul~lll Bride l_Tlllllm~` _-~; ?C BlYde~s .age C J 1 q .7 ` _ ~_'r Date of / / O / I / ~/c/ `J~ 7129 ~:~1, Date of Butll Blltll ke~ldence (~_'ount~-) (State) Residence (c'owih-) (Statel t_iro0111 C~v ~ ~ Bride r~A~- I)ate i-f Al:urlal?e J g 8.Z If Bride Pre~~lou~l~~ 3 ~ ~~ ~.-r Perti-cl t "i-~-ered ~ r I~I<urted, St.~tr Nallle Bt' S catch i Tied at T]lat Tt111e Place ~~-hcre `' (l.L R ~ c~F V ~ ~p ~ L S Place ~~"llere sj- d1~lA~K ~' S ~,v~CK (q ~ u NT~b~N «~ l I I Llcell~e ~~ a~ ~ N ~ £RS W ~P ) - a~ a$e air ~ ~~Q-N~~w ' ~ I~:itecl Petfornled ~ Fie' ~~'hat purpose i~ ulfornlahlxl required, ~~N.E.i.~J FI~~F~l~~9 `.RJR\VEItiS R~-at -~ )~oor relahrn-shtp to person ni-ose record -s requested . :elf. state "self" (,(eErJS~ S~l.r In ~i'hat capacity' are ~'~x~ achu;~' 5~~i^ Lt atta ue}• Nvue wd relahl,--~-tp of }•~x-r dteut to persons „{lose ma-7ia_e record is required. Sl>rnah~~ ~p c~li~~~ I Date ~/Z y~ ? r, J _-~ddre of _~pplicant ~ -~ ~~,11 Please prilit Name and aclclre ~rhere record 1~ to I.,e gent ON WRC ~ J fc'h- ~~K DOH-301 (± 931 tPLE_-1SE SEE REVERSE SII>EI i"S-±~TI N~1N YORK STATE DEPARTMENT OF HEALTH ir...~ ~........r. ems.... Application to TotIImlCity Clerk for Copy of Marriage Record TYPE OF REC EZESiRf~ tEnta®r~~tiittmber of !Codes} Search and Fee $10.00 Search and Fee $t o.oo Certrfied Transcript Pef SPY Certfied Copy PeC SPY A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy includes all d the items d information occumng an the original seal d the townlcity deck. It includes the names d the eonb~acting parties, their record d the marriage. residence at the time the license was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Capy may be needed where proof d parentage and certain other detailed irfamration may be required such as: pass~parts, veteran's benefits , A Certified Transcript may be used as proof that a marriage occurred. court proceedings, or settlement d an estate. BridelGroom/Sp©use Name (as recorded on marriage license): Date of Birth: i ~uy uy ~,'~~ ~~~~ ~ ~rar ,U~ ~' res. r„r ~ O rv ~ arrr Maw. ~ ..~ If Previously Married, State Name Used at that Time: Residence (at Gme of marriage): ~r ~~4~tiG/z S rsadr. tr u tl ~ i9 ~ ~ ~es.S are, ~ &id Cr use Name rded on marriage license): Date of Birth: ~~~ ' ~~,~~~ lor+D~~firNreipN ~- '~ Y ry.r /2f~(JC/z~ ~, r..r S'c~ iJUN '~ errerN.w. d, State Name Used at that Time: If Previously Marri Residence (at time of marriage): e Marriage lnfot~ation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~~ Ir-~1 /~ ~ / 7ew~ ar ~ Toaw a ~/ ~ 0 v~ ~/ . Purpose for wh' rec is required: ~ Date of Marriage or Period Covered by Search: ~ ~ y/L~SCJ~4' w C.~ Mrrirdeaa Sral- ioar In what capacity are you acting?: What is your relationship to person whose record is requred? " ~~~~~ SELF.) (If self, state If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicants Phone Number. / N me of Applicant: Please print name and address where record is to be sent: ~~~~~~s ~~~vvti2 _ --,-, ~-_ - Address of Applicant: //~~ r. .., _..~. r? '' ,~, ~~: JUL n" _ ~y State ZIP Cdy State ZIP DOH301 (8/11) Pepe 1 012 y 1 ;,,.NEW ...YORK STATE ' ~~ DRIVERICENS~ ' ID: 554 ,77Q 402 CLASS D x ;. - ~,. '. ,}SC~1~lON~ ~'"~ r ti-- pACES ;3 ~ s '~ ~ ,.sir ~ EvES 'fit.'` E 'NONE (j. NONE ~' .r: ISSUED: 03.05-12 EXPIRES. Q3-04-20 JUGdHZt@07 NEW YORK STATE DEPARTMENT OF HEALTH Application to TotimlCity Clerk for Copy of Marriage Record ,~...~ o,.,...,~ tee,..;,,., TYPE QF f~EC{?RD DESIRED (Er>ftet' Number of Ct~~i+'s) Search and Fee $10.00 Search and Fee $10.00 Certrfied Transcript ^ Pef SPY Certified Copy per copy A Certified Transcript is an ahslrad from the marriage record issued under the A Certified Copy indudes all d the items d infannation occumng on the anginal seal d the townlaty deck. It indudes the names d the contracting parties, their record d the marriage. residence ffi the time the license was issued, date and place d manage as weA as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain other detailed irrfarmatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod thffi a manage occurred. court prooeerings, ar settlement d an estate. BridelGroorrt/Spot~se Name (as recorded on marriage license): Date of Birth: (orewri..or..rryy ~ Z t~r.r tada~. r,.r trrr~ N.^. If Previously Marri ,State Name Used at that Time: time of marriage): Residence (at ~~,, ``~~ I r-.ar tam. tx ~ sue. ~r' i~ridelGrootrt/Spause Name (as recorded on marriage license): Date of Birth: r„r sr'a~. t..t trrr-trfaw. If Previously Married, State Name Used at that Time: Residence (at time of manage): ~ tam. r~.t aedr Marriage [nforn-ati©n Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: (A [~ v ~1 later ~~/ Te~w r , Teew w Purpose for which record is requi Date of Marriage or Period Covered by Searoh: s,.oa~ In what city are you a ti g?: ~t ~ Y~ relationship m P whose record is required? " ~,,,~ ~~ SEEP.) (If self, ~ j s..d- be v\10~r1 ~..wafi:gprina9 (~w/de/~7ry) If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicant's Phone Number. - Q; 7 ~- ~3 14 ~~-~~ Name o i t: Please print name and address where record is to be sent: Je~n~ ~ . Address of Appl nx ~~ v 1~ aY~hg~ 1 riti~~ ~e 2 ~y State ZIP City Sfeb ZIP DOH~01 (8111) Pepe t of 2 ANEW YORK STAT .~ g. DRIV~~LIC~N~E ID: X24;882 977 ,CLASS D ' ~.AZZ~o ~ ~:- ,~ ` y s ~~~,~~ ~ f -~ SON 2537' OS-0 ' ~ ; 9FX: ~ EYES t . E' NONE ':i, T ~ (~ ~~~'~ R; NONE ° '`-.~Z~ry ISSUED: OB 21 12 EXF'IRE~' 05-02-17 MoDZVNpdO ~` NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vital Records Sedian TYPE OF'ftECORt1 ~ESfFiE D (Entelr f~lumber of 'Cc3pies) Search and Fee $t o.oo y ef co ^ Search and ^ Fee $~ o.oo per copy Certified Co p P Certified Transcript py A Certified Transcript is an abs7act from the maniage record issued under the A Certified Capy indudes aN d the items d information occurring on the original seal d the tormldty deck. ft indudes the names d the oontirading parties, their record d the maniage. residence ffi the time the fioense was issued, date and place of marriage as well as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain oUrer detailed intormat5an may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod thffi a rnaniage occurred. court prooaed'mgs, a settlement d an estate. Groo~lSp©use Name (as recorded on marriage license): Date of Birth: ~mahc~a ~u-n~ ~~put~ (or ap at tor. o/ srni~y~j g-6q-gl ~~.,, If Previously Married, State Name Used at that Titne: Residence (at time of marriage): gg ,~ ~(,~-~Cil'1~S S ~V CouM ~~ Find NCdidi~ !Jd r Bfld@{lr~~~ttSB Name (as recorded on marriage license): Date of Birth: ~oa h ~r~- 3~C,r~vp la+w ar tiro of ar~iay~l ~ ~ ~ I ~_ ~ ~. ~,~. If Previously Married, State Name Used at that Time: Residence (at time of manage): ~~,fch~.~s ~ Fief N6d~ !ad fh~8rr18~8 lnfarrrtation Perfomred: Marriage Certificate No.: Local Registration No.: Place Where Marriage License Was Issued: Place Where Marriage Was '' ~~ t~P,l~ TJt.e.~- IC 5S ~Q,~r .t.~lX~`~~S S ~~- ~ TO~p ~ Town a Purpose for which record is required: Date of Marriage or Period Covered by Searoh: ~ ~~ ~y-zo -l3 In what capadty are you acting?: What is your relationship to person whose record is requred? ~,,,,~~~~ (If sett, site "SEEP.) s..ea t~ I~ ~,..e~ypwio~ ~./de/myl If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant ate: Applicant's Phone Numt~er. - ~-2-tom ~y ~- ~r.~S" -03~ ~ Na e o Applicant: Please print name-aad.add[ass where record is to tie sent: >~mt~ndQ Ca,pvfv ~ ~(~ Address of Applicant: _ 11 ~u m r~r r~ s~- M ~~I~IY-~ TOW (~ ~ ~- a~ _ ,, r T~ ~~ ~ ~~ ~ I ~. ~rG ._ ~~.~, ~l,S~ ~~ l r~ ~~ ~~~~ Cdy a ZIP City State ZIP DOH30t (8111) Page 1 of 2 ,.NE RK STATE; , DRNER.ICENSE ~:.; . ID: 395 ~59 244 CLASS D , , p ~ r+~ AA+4Nl3A J ~ '• ' 1'IS+1 MAIN t' ~ KILL _ ~ : 08-1 SFa(: f EYES 3 E'. NONE ~~ Ap ~' ~' R: NONE '~ ' ,, ~ ~' 09-1&77 HeavrGDM ISSUED: 04-02-40 EXP NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record ..~ ~ W ,~,..M, TYPE OF ~EGQRD QE~IREQ ~Erttsr Number of ~opiss) Search and Fee $10.00 ~ ef S Search and ~~ $1(1.00 per copy Certified Co PY P Certrfied Transcript py A Certified Transaipt is an abstract from the maniage record issued under the A Certified Copy indudes all d the items d infamtation ocauring on the original seal d the townkity dark. It indudes the names d the oontrafting parties, their record d the marriage. residence ffi the time the lio~se was issued, dffie and pace d marriage as web as dffie and place d birth d the bride and groom. A Certified Copy may be needed where proof d parentage and certain other detailed infannffiian may be required such as: passports, veteran's benefits, A Certified Transcript may be used as proof thffi a mamage occurred. court proceedings, or settlement d an estate. $ride{Gcootri]Spouse Name (as recorded on marriage license): Date of Birth: If Previously Monied, State Name Used at that Time: Residence (at time of marriage): \ ~ ~~ IwnT Fief ~ ~ Sf~o &idelt;roos~tlSpouse Name (as recorded on marriage license): Date of Birth: fp~Doerfwl. er..1:y.J ~\^ ~ ~ ~ ~ ~v r~ G.- ~ ~1(~M ~~..~ ~~ ~'J fI~ f'fOf If Previously Monied, State Name Used at that lime: im e of martiage): ce (at t Residen ~ ~ " ~ .!J~h.I G~V.QS=~ ~,V~ 1~ -~ ~ 'v ~ IGdd~~ Laf ~ fdia-ri8f}8 Irt#ormat-on Place Where Marriage License Was Issued: Place Where Marriage Was Perfonned: Marriage Certificate No.: Local Registration No.: 1~-~I pal ~~,~-E,~.e.~~ ~1ek.-5\~-r 1~ Tew1 r Town K Purpose for which record is required: Date of Marriage or Period ~~, ~ ~ y~~`_.h,~ . r,~,,rc~,r• ~ a Covered by Searoh: t~110d 0110/ S..oh fe.C ~ a ~ t ~-~E ~ In what capacity are you acting?: What is your relationship to person whose record is requred? ~,,,,,~~~~ (If self, state "SELF.) If attorney, give name and relationship of your client to person whose record is required: ~~~ Signature of Applicant Date: Applicant's Phone Number. Name of Applicant: Please print creme and address where record is to be sent: Address of Applicant: (~ ~ ~ ~ ~ ~~ D I1~I ~~~ ~ `\ C'~V1(~~~S~t ~, ~ T ~e k ~, Sk1fe ZIP Chy Stefs ZIP DOH~Ot (8111) Pepe 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record ! Vdat Records Section TYPE GF RECORD DESiRf D (Eater Number of Copies) Search and Fee $10.00 Certified Transcript ^ P~ SPY Search and Fee $10.00 Certfeed Copy Per SPY A Certified Transcript is an abstract from the marriage record issued under the A Calified Copy includes aq d the items d information ocamng on the anginal seal d the townlaty deck. It includes the names d the contracting parties, their record d the manage. residence at the time the license was issued, date and plane d manage as well as date and place d birth d itte bride and groom. A Certified Copy may be needed where prod d parentage and certain other detailed irdarrrtatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a tnartiage oocrtrred. court prooeetirtgs, or settlement d an estate. Bridel(3roorrtlS{~ouse Name (as recorded on marriage license): U Sc~ tom. 4~/l~rz`- ~ ~ ~o (~1~L~Sk.i C~ab-~~ICi k Date of Birth: ~ ~ ~ l ~ If Previously Martied, State Name Used at that Time: Residence (at time of marriage): r~,rr wads. t„r ~ atN. &itielQroom/S'po~tse Name (as recorded on marriage license): ~j~l C{,vl V ~1~ ~~a,wS k-l rysr rdwtsi. t.~t asn K.» Date of Birth: ~~ 12 a 8 ~ I If Previously Martied, State Name Used at that Time: Residence (at time of martiage): r•.,t ttxda. t,.r ~" Marriage;tnfor~taf`iort Place Where Marriage License Was Issued: ~N ~p~l~~~ Taws ar Place Where Marriage Was Perforated: ~ a~~~~S ~~.I~ s 7oaw a Marriage Certificate No.: ~~ Local Registration No.: ~ Purpose for which record is required: ~ Date of Marriage or Period Gl C1~ S~ C V121~ Covered by search: tWniod en a Scab iaer In what capacity are you acting?: ~~ (~ I What is your relationship to person whose retard is requred? (If self, state'SELF'.) f,,,^~~~~ sreu tot fir.o.ahHppwioe9 Nw/edl~ry/ If attorney, give name and relationship of your client to person whose record is required: Signatu f Appli t Date: Applicant's Phorte Number. ~-'~ ~ ~-/2'l Na of Applica Please Ixint name and address where record is to be sent: Address of Applicant: ~- --- _ -__~ =' 'u - `'.~~I~INGER r $^~ ri T'~~~td~, , ~r--.._. cty State ZIP City Stab ZIP DOti,901 (8111) Pepe 1 of 2 „,~NE~V YaRK STATE, . ,~. _ ~.~«_.____._~,____.._~_~~ _.~_y~_.~~....._~ DRIVER ~..1CENSE LD: 1:27 516 015 CLASS D PaP~Awsla; .: t LISA,MARIF,~, , „~~ON Np~~' °: 0&19.88-1 ~, SE3e F EVES~'88.1~:'b~6 E: NONE ~" `°" _ R NONE `~ Iu~SUED U9-07-12 rX ~,ES 08-19-17 r2ssMiernnn+ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and ^ Fee $10.00 Search and Fee $10.00 Certification p~ cepy ~~~ ~Py per copy A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the HeaNh Department, includes the names of occurring on the original record of the marriage. the contracting parries, their residence at the time the license was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed infommation may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marriage occurred. proceedings. or settiemeint of an estate. PLEASE PRINT OR TYPE Name (Frs~ (Middle) (Last) Name (Frcst) (Middle) (Last) ~ IJ~ JJ G ~ (' I1 ~ ~ 2V~ +t G of Bride ~A ~ ~ S oom Groom's Age or Date of ~ ~ Bride's Age ~ Date °f 3 Birth Birth Residence (Clounty) °c3room p V ~' L' Yl,e S (yStrate) lV Residence J(County) (State) g ~ C~U'~c ~I,es Date of Marriage Covered ~ / ~ ~ 2 ff Bride Previously Married. State Name /"~M ~ ~ ~ ~ e N ~~ Used at That Time (J t b Sears l 7 Place Where , / License Was ~ ~ Y ~ ~ Place Where (~ / ~ ~ VV A'~P ~ N 4' ~r2 ~Y ~ ~ I 1 N ~ ~ Issued , /~/ p For what purpose What is your relationship ro person whose record is If self, state'self." S ~ ~'~ In what capacity are you acting? If attorney: Name and r~atior~ship of your client ro persons whose marriage record is required. s Application to Town/City Clerk for Coav of Marriage Record of Applicant ~ ~ ~~~ ~ S ~ ~ 2 C IneLsQQ, Ny r2S~(~ DOH-301 (3/9Ci) ~ ~2 ~3 name and address ~ (PLEASE SEE REVERSE SIDE) record is ro be sent NEW YORK STATE DEPARTMENT OF HEALTH Vitat Records Section Application to TotlmlCity Clerk for Copy of Marriage Record TYPE OF RECORD ~E~RE © ~En#~r Number of Copies) Fee $t 0.00 Search and Fee $t o.00 Search and ^ Certified Transcript Pef SPY ~ Certified Copy per copy A Certified Transcript is an absd'act Iran iFre marriage record issued under the A Certified Capy includes all d the items d infannaticn occunng on the signal seal d the towMaty deck. It includes the names d the oontrading parties, their record d the manage. residence at the time the fioense was issued, date and place d marriage as well ~ date and place d birth d the bride and groan. A Certified Copy may be needed where prof d parentage and certain other detailrired information may be requaed such as: passports, veteran's benefds , A Certified Transcript may be used as prod that a manage occurred. court prooeedrngs, a settlement d an estate. BridelGroomt5pouse Name (as recorded on marriage license): Date ~ i ~ ~ ~.' ' ~ 1 ~~\ ~ a-.rrtri... r„r ~r~~ ~P.~'e ~ ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): F„~ ~~~ ~Rddr. t.a ~Q ~ ~1 ~h ~ ter lU &idelGrocm/S~o~se Name (as recorded on marriage license): Date of Birth: br.y..r tr.» er..rlyl r~ \ ~C_~ rr'as. t~.t ~ \ v"~ CiC. ~ eaen N.» if Previously Monied, State Name Used at that Time: Residence (at time of marriage): r~ ~. r,.r c lUlarria~e;lnforrt>satan Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: la-~V ~ Tenn x lh Twn a ~ Purpose for which ord is required: Date of Marriage or Period Covered by Search: ~CS2~\~ ~ ~ s•~~~J ~~~J~ In what capacity are you acting?: t is your relationship to person wtase record is requved? ~~~~~ (If salt, state'SELF'.) ^ 8ord-for ~~ lam' ~+~P~~ f~ldd/llll) If attorney, give name and relationship of your client to person whose record is required: Signature of nt Date: li c aM's hone Number. App c ~ ~ Name of Appli nt: Please print name and address where record is to be sent: ~~ t _-~ Address of Ap rca ~ ~ ~ ~5 JO APR 0 8 201 N OF W ~,~PI TO - -- . City mate 21P City Stato ZIP DOH~301 (61t1) Pape t of 2 ~~ORK STATFF~,, ', ~j3)~'~`'fIFICTlUi~? E',~RD ~ ~` iD: ~ ~~ 1'A;~469 CLASS ID r b.: ti, , s~~+~ ~ h ~, ~ ', w ~~ ~ fli ,. Ski ~ EY .. 1 ~:-'NONE ', ~ ~ ~ ~ R,- NDNE i'r v~a.YC~I 195UED. ~2-01-13 EXPIRES. 01-30-18 ~aNSriuias .f March 27, 2013 Town of Wappinger Falls 20 Middlebush Road Wappinger Falls, NY 12590 (845) 297-5771 To Whom It May Concern: I am requesting research and a certified copy of a Marriage Certificate (or the court record), for the purpose of applying for my Social Security. Lynne C. Peter married to Robert Joseph 13i Bartolo married in the Town of Wappinger Falls, NY date of Marriage September 30, 1972 I have enclosed a personal check in the amount of $10.00, a copy of my current driver license, a copy of my Social Security card and a copy of my Divorce for purse of identifying myself to you as requested by your office and a self addressed stamped envelope. 'ng You, ~l-ti-~-~.. ~--- - Lynn C. Schultz HC 68 Box 3010 6 Windy Flat Mimbres, NM 88049 (575) 590-1178 ---~~D ~~ ppR 0 2 2313 O~ W AppINGE T4W ode ~ ~'>~-~R~ T State of New Mexico ) ss County of Grant ) This letter of request to the Town of Wappinger Falls was acknowledged before me on March 27, 2013 by Lynne C. Schultz -- . ____ ~~ s _.:_ ..__ ._. _ J~ ' ~~~~-V vi ~ J Scott Bodley, Notary Public in and for the State of New Mexico Seal: " o~'~i~ s,"~,u,"" ~~~ ~ ~ My Commission Expires: ~vZ ~~"~ j STIkTE Of IikW MEX~[, _ ~ /~ ~:~, ~~ MY ComrtUpipn Qgiiros `~--C~CJd NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Yrtat Ri:cards season --- TYPE OF RECO#~[3 QE~RE~ (Enter dumber of Capiss} Search and Fee $~ o.oo ^ Search and Fee $~ o.oo ® Per copy d Co rtifi C Pef SPY Certified Transcript e py e A Certified Trarrsaipt is an abstract from the marriage record issued under the A t,.ertified Capy indudes atl d the items d information occurring on the original seat d the townlaty deck. !t indudes the names d the contracting parties, their record d the marriage. residence at the time the license was issued, date and place of marriage as wetl as date and place d birth d the bride and groom. A Certified Capy may be needed where proof d parentage and certain other ' s benefits , detttiled information may be required such as: passports, veteran A Certified Transaipt may be used as prod that a marriage occurred. court proceedings, ar settlement d an estate. BridelGroam/Spouse Name (as recorded on marriage license): S~Cph~~ ~d ~a~~ ~o~mQnr~ Date of Birth: fey ~ is j Fisf Ifid~ Lnf ~ Nms If Previously Married, State Name Used at that Time: R sidence (at time of marriage):~~ (A f~~ e=.~t t~dr, ~ - ,ry sue. 't3ridelGropm/S'imtts~e „> N e (as recorded on marriage license): ~ 2013 ~0- ~~nc~ L~ ors 0 Date of Birth: ~.a. ~...~- C~-~4-~~9~~ 4 APR a~ ~ If Previously Married, State Name Used at that Time: ~ ~; J~~PIN TOWN O ~ i n`~ ^(aAt time of marriage): ~ ~ ~ ~h Fist tlfidds Lad 'Marriage tnfarrnatiun '' Place Where Marriage Li ~se W s Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ ~ ~ ~~f ~ ~ ASS y ,11 ~~ h ~,~/ Purpose for which rr3cord is required: Date of Marriage or Period Covered by Search: Q~ (.~~ ~~ i D l In what capacity are you acting?: What ~ Y~ relationship to person whose record is requred? ~..,~~~ try) " SELF'.) (If self, state ,e1 A s..eu for ~~ (iU' ~>..a~v~-~ glad/m~f4 If attorney, give name and relationship of your client to person whose record is required: Signat Applicant ate: - yJa~'.~ A icanYs hone Number. B uS ~l (~ - U~dC~ Na a of Applicant: Please print name and address where record is to be sent: '~~ ~ ~Y 1 ~'~ ~ Address of A plica~ ~ /~~ ~~ ~~ Stets ZIP City Sfete ZIP DOH~Ot (8111) Pape 1 of 2 ~„rNEW YORK STAT `~ ..:~F-e 1 D~~TVER 'I,IC:'ENSE lD; 520 $8~a.,941 CL,ASS'D RYAN ~ ..; f '~ C,~ITtt~tA,L ~, <~ , 01 01 ~ ~ - ~~, : 'r ~ S®(: F EYES. I? a'00 /~ ' E ~ NONE ''~` ~ / ~! '°~~ 13SW~: 12-2412 EXPIRES. 01-01-2U oescruesi s NEW YORK STATE DEPARTMENT OF HEALTH Yrtal Records Section Application to TownlCity Clerk for Copy of Marriage Record TYPE OF RECORD DESfRfv >a (Er>ftar f~iwmber of Copies) Search and Fete $10.00 Certified Transcript per copy Search and Fee $t 0.00 Certified Copy ^ per copy A Certified Transaipt is an abstract from the manage record issued under the A Certified Cflpy includes all of the items of iMormatian occurring on the original seal of the townlaty Berk. It includes the names of the carraading parties, Char record of the marriage. residence ffi the 6me the license was issued, dffie and place d manage as well as dffie and place of birth of the bride and groom. A Certified Transaipt may be used as proof thffi a manage occurred. A Certified Capy may be needed where proof a# parentage and certain offier detailed irrfarmation may be required sud- as: passports, veteran's benefits , court proceedings, a settlement of an estate. BrfS~ Gf S~poaB@ Name (as recorded on marriage license): Date of Birth: (or ep ar rte o-eerrtep~ If Previously Monied, State Name Used at that Time: Residence (at time of marriage): tom. &id roomtSpouse Name (as recorded on marriage license): ~ T Date of Birth: fa-eyrettieeereeniyy txraa. ~nx~~~ ~ ~~f' a N erer- rr.~. ~ ~ --~02 - 7 If Previo Married, State Name Used at that Time: Residerx;e (at time of manage): rest nr`dr. ~ ~ str~ 'Marriage: Rn#orlnation Place Where Marriage License Was Issued: {,~cc~~- ~~S . ~~c~sS Place Where Marriage Was Performed: ~~ ~~~ J ~~ Marriage Certificate No.: ~teeewiy Local Registration No.: ~~-- Teen ar T Purpose for which record is required: _ /~~~ ~~~~( /~ ~5,~ ~/ ~{,~,Y` Date of Marriage or Period Covered by Search: IMi~doaa SraM hoer In what capacity are you acting?: What is your relationship to person record is requtied? (If salt, state "SELF'.) ~,,,~~~~ s..eU for er...a-+:~yp.-iedt I..led/1717t If attorney, give name and relationship of your client to person whose record is required: Signature of Appli Date: Applicant's Phone Number. - ' -a~-13 ~Ys ~ 3z-~ 2~7 Name of Applicant: y, f~ ~_~~ Q LC (~~~~~~ /~(~r Please print name and address where record is to be sent: ress of pliant: ~~ 'n ~``°r ~/~ . ~ ~e ~`2~ ~ . `~ ~ Z6CJ City State IIP City S~ ~p DOH-9o1 (8111) Pape 1 of 2 ,,,,,,~TEVV :.YORK ST NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record vital Records Section TYPE OF .RECORD DE~fRE D (Enter Number of Codes) Search and Fee $10.00 Search and Fee $~ o.oo Certthed Transcript Pef ~pY Certified Copy ® per copy A Certified Transaipt is an abstract tram the marriage record issued under the A Certified Copy indudes all d the items d information ocatmng an the original seal d the townlcity deck. It indudes the names d the corrtracfing parties, their reard d the marriage. residence ffi the time the license was issued, dffie and place d marriage as well as dffie and place d birtlr d the bride and groom. A Certified Capy may be needed where prod d parentage and certain other detailed information may be required such as: passports, veteran's benefits , A Certified Transaipt maybe used as prod thffi a manage occurred. court prooeedmgs, ar settlement d an estate. -i3rid Spouse Name (as recortied on marriage license): Date of Birth: (oreyeetiwe~arri~j II ~ ~OCr~ ~ ~ ~ }-fie {d,iJ 5 Bir~tirew. Qy /7'!96 ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): fi~tics P ~ ~ F~ ~ t„r „ s collar sM. Bn Groom/Spo~tse Name (as recorded on marriage license): Date of Birth: IaeDeaf 6eeoree~ F.~ ~ ~ ~. ~ ~ N ~ P~s .~r~.. of -a~,i If Previously Married, State Name Used at that Time: Residence (at time of marriage): r-.,r mar. ~ arse Marriage tnforrrtaf~n Place Where Marriage License Was Issued: Place Where Marriage Was Perforated: Marriage Certificate No.: Local Registration No.: le~l !ate) ff Toaaor ~ n a chcs~ Toaaer W4 in cn3 Purpose for whi h rec rd is required: ~ Date of Marriage or Period Covered by Search: wniden w sear tom. b In what capacity are you acting?: What is your relationship to person whose record is required? ~ ~~~ (If self, state "SEEP.) Sead- be F-...arngpwis~ (Y.n/dN/aril If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicartt's Phone Number. ' i~ ~ ~~~ S~= ~y 1 _ ~/ ~ ~i 7 Name of Applicant: Please print name and address where record is to be sent: Address of Applicant: Cdy State ZIP City State ZIP DOH301 (8Iti) Page 1 of 2 ~NE~V ~.~ORK STATEI_-~ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH ~;~ Records section for Copy of Marriage Record r Fee $10.00 ~~ ^ Fee 610.00 P~ SPY P~ ~p1+ A Certification. an abstract from Use marrie~ge record issued A Certified Trrarracxipt includes aN of the items of information under the seal ~ the Heattl~ Department, inckxtes the Heroes of occurring on tl~e original record of the marriage. the contracting parties. their residence at the time the license was issued as well as date and place of girth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed irHonnation may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marriage oxiured. Pte, or settlement of an estate. PLEASE PRINT OR TYPE Name (Frstj (Middle) (Lasq Name (F~rsQ (Midge) (Last) Groom ^ ~o~~ 1^1 L- .~ ~S '~' Bride ~ {,~-. JS ~ ~ ~[~ o ~ G Groom's Age Bride's Age or Date of Birth 7/ ' b ~~ (~ e~ ~ c~ ~'-I f "7 .~ Residence (County) (State) Residence (County) (state) cxoom .D~s'rc.-~.c s~ ~T' ends ~Lhcss N1~ Date of Marriage ff B~ poly or Period Covered ~ Married, Stale Name sears, c~.~, oo used at That rime Place Where Place Where lsawas ~Q ~~eL,s ~~~~ N i Pew ~ P6~'~, kt{PS;Q N~ For what purpose is inforrr>etion required? 1"o Q e ~- ~e r~ac ~ ~ c~ What is your relati ff self, stabe'aetf.' Se I ~' to person whose record is In what capactity are you Signature of Appgcant t i~,,,~,ll., n of Applicant 1 UC'li~ Q1vt B c~~ ~'t b~I'~ ff atlomey: Name and rela4ionstap of your diem ro persons whose marriage record is required. ease pant name and address where is to be sent I ~/a,~ Awe., _ (3eo.cor, ~; ~a ~$ ~~~0 D d D DoH-so, (6198) (PLEASE SEE ~~~~ cp ~~~~- sID~ APR 12013 TOWN OF WAPPINGER ___TpWN CLERK ~, ..rr~.~. ~..,- R.K STATE .,~ ~ 4 d~ _~. tisF~ ~:; ~'~: 288 560 p22 CLAS Y-..~ $~ 1D. ' 4~fi ~.. ~~~~~"'~ A•F`. pFAYEI'~ p+~ ~ 'F h~ ~" 3q}., NY t3t~ ~ '10~+Ta ~,.. ~ ~ fig. ~ lif: ¢40 E: NONE R NONE EXptRES 07.10-16 9aessoe March 30, 2013 To Whom it may concern; I would like a copy of my marriage license showing the name of the officiant. Please send it to 1 Vail Ave Beacon NY 12508. I was married in Poughkeepsie NY on Jan 3, 2000. I was issued ~ marriage license in Wappingers Falls NY. I was married as Joseph Best to Melissa Sedore. I am now known as Joseph Colbert. m~~ Cw t~ee~~+ . Thank you, Joseph Colbert ~tJE:.%r3t3Ec: f+,~1a S~~ORM1E TO t3EFOrZE Grit t3Y- •Jc~SeOR <a~.1.~~f ,. J~ ~~ Ti4fZY P tC • ~~ ~~~~•` GREGORY J RELYEA Notary PubllC -State of New York NO. O1 RE6170699 Quallfled In Dutchess County My Commissirn Expires ~e/Zoo NEW YORK STATE DEPARTMENT OF HEALTH General Information and A lication for Genealogical Services Vital Records Section, Genealogy Unit pp VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES. Return to: New York State Department of Health, Vital Records Section, P.O. Box 2602, Albany, NY 12220-2602 1. FEE - $22.00 includes search and uncertified copy or notification of no record. 2. Original records of births and marriages for the entire state begin with 1881, deaths begin with 1880, EXCEPT for records filed in Albany, Buffalo and Yonkers prior to 1914. Applications for these cities should be made directly to the local office. 3. The New York State Department of Health does not have New York City records except for births occurring in Queens and Richmond counties for the years 1881 through 1897. 4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical research. To insure a complete search, provide as much information as possible. Please complete the applicable section for each type of record requested: birth death or marria e Name at Birth Date of Birth Place of Birth Father's Name Mother's Maiden Name State File Number _ C ~ m Name at Birth Date of Birth Place of Birth Father's Name Mother's Maiden Name g. State File Number ~ Name of Bride ~ Name of Bride ,~ Name of Groom ~ Name of Groom L ~ Date of Marriage Nuamberle y„ L ~ Date of Marria a 9 State File Number ~ Place of Marriage ~ Place of Marriage and/or License and/or License Name at Death Edward ~. DUnni gan Name at Death Date of Death ~Uly 20. 1934 Age at Death 38 Date of Death Age at Death = s ~ Place of Death Wapl)Inger ~ Place of Death p Names of Parents Frank Dunnigan Ellen Whalen Dunnipan ~ Names of Parents Name of Spouse Hale) R. Name of Spouse State File Number 44084 State File Number For what purpose is information required? FamIIV HIStOrV What is your relationship to person whose record is requested? I am Mr. Dunnigan`s grand-niece In what capacity are you acting? SIGNATURE OF APPLICANT /'^-l~'~'r-`~- ~ DATE -3 Address 302 Brockton Road. Wilmington DE 19803 Phone (302652-8176 Send record to: (please print) Name Susan Kirk Ryan If requestingbirthavd marriage records, please sign the following statement: To the best of my knowledge, the person(s) named in the application are deceased. Address 302 Brockton Road city Wilmington State DE Zip Code DOH-4384 (12105) Page 2 of 2 OF Susan Kirk Ryan 302 Brockton Road Wilmington, DE 19803 (302) 652-8176 kirkryan302~a aol.com March 9, 2013 Town Clerk Town Hall 20 Middlebush Road Wappingers Falls, NY 12590 Request for Death Certificate -Edward , Dunnigan Dear Sir or Madam: I write to request a copy of the death certificate of Edward J. Dunnigan, who died on July 20, 1934 in Wappinger. From the New York State vital records index, I understand the certificate number to be 44084. Enclosed please find a check for $22.00, and the New York State application form, as recommended by the Duchess County Genealogy Society website for requests to your town. Thank you for your assistance. Please feel free to contact me with any questions. Very truly yours, ~~~~.~,~ Susan Kirk Ryan Enclosures NEW YORK STATE DEPARTMENT OF HEALTH General Information and Application Vitai riecoras SeeSon, Ge-+eriiciy-~i urit P.O. Box 2602 Albany, New York 12220-2602 For Genealogical Services VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES. 1. FEE - =22.00 includes search and uncertified copy or noi~iCafion of no n~oord. - 2.Orignal records of births and marriages for the entire state begin wih 1881, deaths begin with 1880, EXCEPT for records fled in A~any, Buffalo and Yonkers prior to 1914. AppNc~tions for these aTies should be made directly to the bear office. 3. The New York State Department of Health does not have New York City records except for births occurring in Queens and Aidtrnond counties br the years 1881 through 1897. 4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years available for genealogical research. To insure a complete search, provide as much information as possible. Please complete for type of record requested, birth, death OR marriage. Name at Birth ~~~ ~~ Lv,~nv\ ~-1ay-r~S Date of Birth '~ ~ Z t 1`~ y~ Place of Birth Name at Binh ~7U1 ~~ ~w1~ Date of Birth ~ ~ "~ ~ ~.. Place of Birth ' `~r~ ` ~ ~f ~S Father s Name ~' Fathers Name ~U~` ~P ~~~` ' ' Mother s Maiden Name . ~ Mother s Maiden Name Name of Bride Name of Bride Name ~ Groom Name of Groom - ~t ,~ Date ~ Maniage _ Date of M aiage ~~ Place ~ Marriage ~ and/or license anryor ~ "-,r ~^~r°~$-~-~-`:~ `. ~ a~ esth ~\c,~~"C>1 C) ~~Vl S Name at D~agicR s ; ` ~ Date of Death ~~~ Age at Beath ~a~ ~ Date of Death Age at Death Place of Death Place of Death Names ~ Parents Name of Spouse Names of Parents Noma of Spouse For what purpose is information required'~,~MUQ`~7~ti What is your relationship to person whose record is requested? In what capacity are you acting? .___ - ~~ SIGNATURE OF APPLICANT DATE ADDRESS '~ 1\\- ~ VJI~~~Xan ROSS ~ (~~yy1S('~1,`~ ~(~1`- Z~-1~b to: Name ~~ ~ ~ ~ S ~ ti`l ~ ~ Ce ~h5 Address ~~~" ~~ V~~~kwti~y~ `~r~SS LQ,inz aty V~1~~vt~tJ~l~state ~~ z~pcode24~~~ statemer~ To the hest of my knowledge, the person(s) named in the application ...are deceased. SIGNATURE OF APPf1CANT DOH-1562 (06/20001) ~f ~~ ~~C-~~~ ~~~ (over) February 27, 2013 Untitled I am looking for tax or voting records in Wappingers Falls for Louise Harris, widow of Harry Harris. that would indicate her home address. They lived there in the early 1960's (1960-61 at least). I am doing genealogy research on grandmother. I do not need birth, marriage, or death records but have included the form and payment as requested when I contacted your office about this records search. Delores Wil!iarr-s Page 1 NEW YORK STATE DEPARTMENT OF HEALTH General Information and Application Vital Records Section, Genealogy Urut P.O. Box 2602 For Genealogical Services Albarry, New York_ 12220-2602 l VITAL RECORDS COPIES CANNOT BE PROVIDED FOR COMMERCIAL PURPOSES. 1. FEE _ 122.00 inductee search and uncertified Dopy or no6rfication of no record. 2.Original records of births and marriages for the entire state begin w~lh 1861, deaths begin w~lh 1880, EXCEPT for records filed in Albany, BuBalo and Yonkers prior b 1914. AppdCations for ttrese cd6es should be made directly to the kx~l office. 3. The New York State Department of Health does not have New York City records except for births occurring in Queens and Richmond counties for the years 1881 through 1897. 4. Please read the Administrative Rule Summary on the reverse side of this sheet which specifies years evadable for genealogical research. __ To insure a complete search, provide as much information as possible. Please complete for type of record requested, birth, death OR marriage. Name at Birth i~o~er ~' ~~n ~U P~ S ~ ~ r Name at Birth Date of Birth IYIa rc ~ ~ l / 9a. l Date of Birth Place of Birth W~~ ODD /1 Q ~ }'a IIS V V '~I Place of Berth ~. Father's Name ''::,. Father's Name Mother's Maiden Name Mothers Maiden Name Name of Bride Name of Bride Name of Groom Name of Groom Date of Marriage Date of Marriage Place of Manage Place of Marriage :. andlor Ucense andlor license Name at Death Name at Death Date of Death Age at Death Date of Death ~ ~ t e Place of Death Place of De MAYS Q ,q ~ .Y~ Names of Parents , -~--- Names of s<: Name of Spouse nr N OF Name of use __.__ R For what purpose is information required? What is your relationship to person whose record is requested? ~ o n In what capacity are you acting? ~~ ~~ ;/~ ~ 5 ` 02 ~ -oz c'7 w2 F APPUCANT.~r'~'~`"~ ~'`~'~ ' O SIGNATURE DATE r / ADDRESS ~"~ ~ Gv~ ink.)`-sue ~~~prv~i~,e ,~/~ ,~,ri Sao Send record to: (please print) If requesting birth and marriage records, please sign the following s~atemer~ Name To the best of my knowledge, the person(s) named in the application are deceased. Address City State Zip Code SIGNATURE OF APPLICANT DOH-1562 (0612003) (over) (~ 4V~( y NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record try Records Section TYPE O~ RECORD QE~1RE ~ (Enter f+lwmber of Codes):... Search and Fee $t o.00 ~ Per SPY Search and Fee $i o.oo PeC SPY Certified Co Certified Transcript py A Certified Transcript is an absfrad from the marriage record issued under the A Certified Capy includes all d the items d irdonnation occuning on the original seal d the townlcity dark. n includes the names d the oarireding patsies, their record d the marriage. residence at the 6me the license was sued, date and place d marriage as weU as date and place d birth d the bride and groom. A CerGfiad Copy may be needed where prod d parentage and certain alher detailed Mfarmatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage oocu-red. overt proceedings, ar settlement d an $ridel(3rooml5~ulse Name (as recorded on marriage license): Date of Birth: (o..y. ar i.. or..rtyl ~ 9/~ ~~~ ~ ,~, a e.. ~ ~,, a a ~ ~ If Previously nied, State Name Used at that Time: _ Residence (at time of marriage): Fnd IRdd~ lart ~' 81~ BridelGrcromlS~ottse Name (as recorded on marriage license): Date of Birth: Ia+D~af 6M of arriyy 1 l ~~~- ~. ~-s ~ ~~Q~c~ ~~, 5 ~ 8 ~ r If Previously Monied, State Name Used at that Time: Resider~e (at time of marriage): ry.r rrddr. Wr ~h alar Marriage :Information Place Where Marriage License Was Issued: Pface Where Marriage Was Perforated: Marriage Certificate No.: Local Registration No.: ~ ~~~ ~~s ~~ ~` p ~ `'w~S 11 Y match ~ra...r p~- ~ .~~. CIS s -~. rew~« rse for which record is required: Date of Marriage or Period Covered by Search: ~~~ r3 What is your relationship to person whose record is requked9 ~ ^ity are you acting. ' .) (If sell, state "SELF srau 1a: ~si.dmyp..ina~ (wwldd/f~- ~e and relationship of your client to person whose record is required: Date: AppNcanrt's Phone Number. ^ ~ 6~ (3 Please prird name and address where record is to be sent: ~~~ ~)P. s ~t 7~-/ 1~~5~6 State ZIP Cdy SIaM ZIP ~(2~ ~~-- -__ - .-- ~ RK STAT T-- °_~.. DR1VI±:R~~~NS tD: ~s2.~7~ .683 CLASSD ,. ~~f~ ~: +k ~, ~` ;sate ~ ems '' ~~~{ (_ iS~UEC1' .07,19-10 EM~IRES~ 08-1:8-15 w6icNFl.wv~ Application to Local Registrar for Copy of Death Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ J LA - (~ ~ ~L~'ie ' e~rc~, 'i CJYI V First Middle Last Name f Father of Deceased First Middle Last Maiden Name of Mother of Deceased ~1~~i~. ~~- nP~ First Middle ~ Lit Place of Death ' 5 ~~~so~~nv -e.J Name of Hos ital or Street Address Purpose for Which Record is Required Age at Death 1~5~e r/ ~ ~ ~ What was your relationship to the deceased? 'i ~ ' "' ` In what capacity are you acting? . If attorney, name and relationship of your client to deceased ~'1 O ~'e--- C\ n ~ ~ ~-. (~,-~,,,, r, a ~ ..___ ~~L`'-~e-o ?~ X013 Signature of Applicant Address of Applicant _ Date of Death or Period to be Covered by Search ~ ~-~~ ~~g Social Security Number of Dec~~ a~~~ ~ . Date of Birth of Deceased Month Da Year vinaae. Town or Citv ,n v ~- tZ umber of copies requested with confidential cause of death Number of copies requested without confidential cause of death V~ DOH-294A (6/2000) ''~.~~ -;~~ /~ , DRIER ~,ICENSE ID: X82 229 440 CLASS D 'NONE ~ ~` ` ~~rru./~~ ISSU® 03-01.12 DtPIRES 03-01-20 zsccowaw ^ Christine Fulton TOWN CLERK Town of Wappingers Falls, Town Hall 20 Middlebush Rd. Wappingers Falls, NY 12590 APPLICATION FOR SEARCH OF DEATH RECORDS DATE: June 11, 201.3 FULL NAME OF DECEASED: Naser M. Abdelhady DATE OF DEATH: March 24, 201.3 PLACE OF DEATH: 35 Downey Avenue, Wappingers Falls, NY 12590 APPLICANTS RELATIONSHIP TO DECEASED PERSON: Attorney for Naser M. Abdelhady's estate NUMBER OF COPIES REQUIRED: 1 (FEE FOR EACH COPY: $10.00) PURPOSE FOR WHICH RECORD IS REQUIRED: Probate of estate NOTE: PLEASE FORWARD THE LONG FORM CERTIFICATE. THANK YOU. SIGNATURE OF APPLICANT: ADDRESS OF APPLICANT: McCabe & Mack LLP P. O. Box 509 63 Washington Street Poughkeepsie, NY 1.2602 ~n\~~ V 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. ;..,, Pl.~q~~ PRINT O.R TYf?~.,. Name of Deceased .Date of Death or Period to be Covered by Search ~'~~nG(Sco .~ac~.sr~ ~i~llr~c Z8 , Zc~ 1~ First Middle Last Name of Father of Deceased Social Security Number of Deceased 1~d t 1~t~t /~ ~ra~e.~-~a o 9 ~- - ~ ti - `i ~- `t ~ 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 `` '[~ -I `^l~„~,~ t y.,,~ ~ ~~~~ Name of Hos ital or et Address Villa e, ow or Cit Count f Whrch Record is Required Purpose or ~~~ Q ~ ~-~ ~ !~-~ i ~ t`~ t What was your relatronshrp to the deceased . In what capacity are you acting? ~n ~l If attorney, name~nship of your client to deceased Signature of Applicant Address of Applicant _ d~ -~~- i of copies requested with confidential cause of death Numbdr of copies requested without confidential cause of death Name _ Address City __ f)C)H-294A (6/?0001 State Date ~ _ ~ (3 Zip Code o.~~~- NEW YORK STATE DEPARTMENT OF HEALTH .,:.~i Ce..n.~c Coetinn Application to Local Registrar for Copy of Death Recor FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased ~~~~ ,s First Middle Name of Father of Deceased ly /ICt~rc ~ ! ~ . First Middle ~~~~ ~~ Last y ~~ezeli./ast Maiden Name of Mother of Deceased 2.~., ;~ .Sum k ~/:~. First Middle Last Place of Death ~ 3 p~~ ~ ~ ~~~ •r ~~~Oc 1' Sir Name of Hospital or Street Address Purpose for Which Record is Required ~ P y c~SZ ~~~ vJ ~'' Date of Death or Period to be Covered by Search Get ~7, ~~~ y Social Security Number of Deceased Date of Birth of Deceased Age at Death Month 3 Da ~ ~ Tear 6 S i F~~~f~ ~u t~ G~ Villas~e, Town or City _ County What was your relationship to the deceased? ~ ~ o f ~ ~ In what capacity are you acting? If attorney, name and relationship of your client to deceased ~ '~ ~ ~3 Signature of Applicant "" Date Address of Applicant .S - ~ ~`' ~ S-s' 0 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 <<~ ,~ E YORK STATE ~.. `~ _ - _ D,y~I~. LICENSE ID: 20.9.;874 689 CLASS D DONNELLI~'`a. s ~7SAN ~: ~~ ~( M EYES '~+ ~ 0 R B"F ~` '~ -i ~~ lSSU6D.12~-19 E.vi%_5.12-D7-i9 ~tFNY1E~ NEW YORK STATE DEPARTMENT OF HEALTH ..._, e~_-....J.. Csnfinn __ Application to Local Registrar for Copy of Death Reco FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. Name of Deceased tl~~`~ }~r~\c~. First Middle Last Name of Father of Deceased ~. ~drv~C~ (bM~~Rs First Middle Last Maiden Name of Mother ,oQf Decease ~ ~r 0. First Middle Last Place of Death to ~°~r~lc-~~ r'~ ~" Name of Hos ital or Street Address Purpose for Which Record is Required Q~,rSvr~~ Date of Death or Perwd to be Covered by Search ~~ a~~ iv Social Security Number of Deceased Date of Birth of Deceased Age at Death I i~~ 1 ~~- Month ~ ~ Da `1 Year village. Tor City County What was your relationship to the deceased? GV 1r~'t In what capacity are you acting? mt C If attorney, name and relationship of your client to deceased Signature of AppNcan' Address of Applicant Number of copies requested with cor~dential cause of death Number of copies requested without confidential cause of death Name Address C'rty _. DOH-294A (6/2000) State Zip Code ~I~l~ ~TEV~ RII~STATE I~RTVER~~..ICENSE 1D: 399 X01 768 CLASS D _. ties ~ a .,~ _ ' .~ . c,' ~ ~4 ~ ~ ' ~ E;1if~NE '~~' , ~ ,' ~^"~, ` 1, 03-18-09 FJ~IRES: 03-Ot-77 wKrscc+~w~A ~~ ~ ~~ I, ~ i _~t4 ~~ Ms.JennlferTomlins 219 Osborne Hill Rd. Fishlcill, NY 12524 E: {NON.) V ._.y~ r t ,~~ ,~ ~ , in .nv mexe en ne~wn~cei p.n. ---~. ~~ _a'~~;o - - _ _ `'A: =bPREC'ivE ~EivsES Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEA a~ C~gIIIIPLETE Fl3RN1 Ai~tD 1~NCi~t`3sE IPEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. RII,;F.ASE~:Ptt1NT 4R TYPE Name of Deceased Date of Death ar Period to be Covered by Search David Charles Hengst July 14, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Charles Hengst 074-80-5142 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ]Mary Cataneo October 9, 1991 First Middle Last Month Da Year 21 Place of Death 7Ardmore Drive Wappingers Falls Dutchess Name of Hos ital or Street Address Villa e, Town or Cit Coun 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 ~'~~~~~'`~ l 17 '~~'~- 2013 Ju y , ~ Signature of Applicant Date Address of Applicant 895 Route 82 Hopewell Jct NY ca r R ~ RE a~ ~ ys~s 10 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death PkEAS PR1:1~1T f+i . E aN A~p~RESS WMEt~ t>! #1HOULD BE: SEN'T` Name ---._. Address City _ State Zip Code DOH-294A (6J2000) ~~~~3~-- Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section ..:,. PLEASE COMP~~'T'>C [=~f~IVI ANp ~NG:I~QS~ f=EE ,:::..,;: FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. -f~L~AS~ P: .. .. .:. FfINT OR TYPE Name of Deceased ,, ~ ~ ~ .Date of Death or Period to be Covered by Search J~J~ ~ • \ a~~`~-d~~~ First Middle Last Name of Father of Deceased 1 (~ ~ ~ Social Security Number of D e~ceased c First Middle Last Maiden Name of Mother of Dece ed Date of Birth of Deceased Age at Death ~ Q?!~- ~v YYZ V1~1~ ~Y " ~ 'S ~ ~' ~ ~ ~ ~ 8 r Y ~ ~ first Middle Lash e a a Month Place of Death ~ ~ ~~~ ~ ~- ~~ss Name of Hos rtal or Street Address Villa e own Cit Count Purpose for Which Reco~d(is~Required ,~/ • What was your relationship to the deceased? ~~ ~ ~~- ' "' In what capacity are you acting? ~. `~,~a~~ ~~" If attorney, name and relationship of your client to deceased Signature of Applicant Straub, Cal ate ~ ~ ~_- '/ Funeral t~~c~rYie Address of Applicant ,~;> ;~r5t ,~~1ain Strcot wa , .:., . , ..,. . '':.< COMPLETE FQR DEATHS Q:Ct~U.. RIND AS Ot* JAN '. ~ ~9& 5+"~ Number of copies requested with confidential cause of death ~_ Number of copies requested without confidential cause of death Name _ Address City T nOH-294A 161?0001 State Zip Code '~/iS//3 NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $:30.00 /Other District - $10.00 ;per :certified copy ar No Record Certification Identification Requirements: Application must be submitted with copies of either A or B. (Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.) A. One (1) of the following forms of valid photo-I D: -0R- B. Two (2) of the following showing the applicant's name • Driver license and address: • Non-driver photo-ID card • Utility or telephone bills • Passport • Letter from a governmen agency dated within the • U.S. Military photo-ID last six (6) months Name of Deceased: Social Security No. of Deceased: John F. Hafner 064-20-0022 First Middle Last Date of Death or Period to be Covered by Search: (mm~dd~yyyy~ Date of Birth of Deceased: Age at Death: 07/22/2013 04/04/1928 85 From To mm 1 dd / Maiden Name of Mother of Deceased: Death Certificate No.: (lf known) Katherine Breitfeller First Middle Maiden Lasf Name of Father of Deceased: Local Registration No.: (If known) Frank Hafner First Middle Last Place of Death: 334 Cedar Hill Road Wappinger Dutchess Name of Hospital ar Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without confidential cause of death.) Copies requested with Copies requested without Total number of confidential cause of death 6 confidential cause of death copies requested 6 Purpose for which Record is Required: What is your relationship to person whose record is required? Funeral Director In what Capacity are you acting? If attorney, give name and relationship of your client to person whose record is required: Funeral Director If you are not the parent or chiid of the deceased or the spouse of the deceased at the time of death, you must submit documentation of a'lawful right or claim. Date Signed: Signature of Applicant: Moron Da near FOR RECihSTRAR'S U$E "ONLY (Photocopy ID and att~h to application form) 07 24 2013 Type of ID: U ^ Driver License Address of Applicant: Issuing state.: Anthony J. Calabrese Expiration date.: (AppticanYs Name) Number: 1028 Main Street ^ Other iD, S,pecfy (street) Number: Fishkill NY 12524 Type: (GtY) (State) ("Zip) N urn ber: Telephone No.: ( )(845) 896-6166 Type: ~~L//~ NEW YORK STATE DEPARTMENT OF HEALTH ~/ital RarnrrLa Section Application to Local Registrar for Copy of Death Record :• . :• ~w~: - {i$i<E ~;:r• <.:;. .J :~! : FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. . .........: ... :.: .::: v:.vy.,w::::......:....,.n.~~i.:O:~v:: i:i iijii :. .: ..n ':/ .{..... n.... n.. ,.:rn ....... v. r.. ....::n:::::::::n....-0:nw:•:::4::4:fiiY.y?::i:. .. .;:::n.•n„~::::::. ',~4.:}. ~: .v: ••!v: ~•:}}. ~.'~:.i n ;r::::: ~ :::::::::::::::::::: ....... r ...:.... ....... ~.. r. . . ..:. ~~:v::<. ..... :..::. . ~::.::.:.::.v:. :::>:......::.. ..:....:.... ..::..; .::.......: y. ;. .:,: ,.... .:..:.;:,:,:::.:::,.:...;:. .. ..:. ::i/ti:l.,:$:•:: ii::4:.w'. Name of Deceased Date of Death or Period to be Covered by Search I~YI ~ C 1~c,-~ ~ ~ ~ ~~ ~~ First Middle Last Name of Father of Deceased Social Security Number of Deceased ,• ~~ , _ ~~ __.- First Middle Last -- ~ Maiden Name of Mother of Deceased of~Deceased Date of Birth Age at Death r_ ~ ~ l9 ~~ First Middle last Month Da Year ~ ~ ~~ Place of De~h , w ~ ~l i u-~`~~~ ~ u ' .Name of Hos ital or Street Address Villa r C Purpose for Which Record is Required -What was your relationship to the deceased? N~~ In what capacity are you acting? N S r~ If attorney, name and relationship of your client to deceased ant f A li Die--~~ ~ c Si nature o 9 PP Address of Applicant Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name _ Address C'tty DOH-294A (6/2000) State ZP Code ~1~1~3 ,Application to Local Registrar NEW YQRK STA'T'E DEPARTMENT OF HEALTH fOr COpy Of Death ReCOrC~ Vital f~ecords Section FEE=: $10.00 per copy or No Record Certification. Please do not send cash or stamps. - .. ..... . Nam.=_ of Deceased Date of Death or Period to be Covered by Search FLl2~~N N . Gvr;~~~2 ' ~ __ First. _ Middle Last ~® ~/ Nar e of Father of Deceased H~ ~ue ~ ~c ~ Social Secu rit y Number of Deceased , ~rn ase~ ) y ' 2.Z- 7~~~ ~ _ First. Middle Last l0 e o Mother of Dece a s ed a iden Nam f M Da te of Birth of De ceased Age at Death CC t '~ ,a~ „ }~~ ` j ~ t IL(.- 1 Z~(3fzi [7 / >~ ~ 1~! 14 ~Q • 1 ~ / ~'J h `~ x `~ C ~ C/ 6 ~ 7~ ~~ _ First___ Middle _ Last ~~ ~~ ~ Month Da Year _ Plac~a of Death v_V - ~G~'~-r~ - ~ ~/%s0/!~'~j'G`S ~'~,~ w~f~`.~14~i'~ ~~Ll. S ~.J'i~h~Ss` Name of Hospital_or Street Address illag Town or City _ County Purpose fur Which Record is Required What was your relationship to the deceased? ~~C~~! _ ~t v'CC_~?_____ --- -- Inwhat rapacity are you acting? ______,__ ~._ l~ _ 1Q. - li attorney; name and relationship of your client to deceased Signature of Applir.,ant ._._` _ ___._ Date ~ ~~ _~~~___ Address of Applicant ---___~1- ~~~ S~~'o `F -0.'1-- /?~/~S~~_- - l'0 ~~---- --- --- -~-- IVumber of copies requested with confidential cause of death __________ IVumber of copies requested without confidential cause of death UGH-294A (6/2000) .ra 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 ,eve ~,er ~'1- ~vl L/~~s S ~ ~ 1 ~~-~' 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 yL7 Age a1t Death ,, First Middle Last Month Da Year Place of Death ~ ~~G~ ~J~ ~~ `~oZ S~ i ~~7 Z-~ ~ p~ ~ ~~ t/lr~i Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpose for Which Record is Required ~~n~ L~ ~ ; r~ ~~ L t ~,E > ~ vC s What was your relationship to the deceased? In what capacity are you acting? ~ ~- ~ -~ ~~ STl C~~~ ~ If attorney, name and relationship of your client to d ceased ~~ Signature of Applicant - Date- Address of Applicant ~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name f~~ rTl ~r1~,~ / ~i~~'/~ Address ~ ~ /~~ /J/J1.Y~~~S/~ /~ City ~,/`~/~/~~ ^'l~/z-S FA Z,LS state zip Code loC S ~1 ~ DOH-294A (6/2000) °N~W YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: County District - $30.00 l Other Districts - X10.00 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#ram 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: Robert Myers 196-32-4810 First Middle Last Date of Death or Period to be Covered by Search: (mmidd~yyyy) Date of Birth of Deceased: Age at Death: 05/31/2013 06/28/1940 72 From To mm / dd ~ y Maiden Name of Mother of Deceased: Death Certificate No.: (It known) unknown First lliliddle Maiden Last Name of Father of Deceased: Local Registration No.: (If known) unknown First Middle Last Place of Death: 42 Scribo Lane Wappinger Dutchess Name of Hospdal or Street Address Village, town or city County Number of Copies Requested: (For deaths occurring as of January 1, 1988 specify with or without con6dentia/ cause of death.) Copies requested with I Fa+:.e. FeR Copies requested without Total number of 1 confidential cause of death+Sac~AC 5¢w~rESconfidental cause of death copies requested 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 dec®ased at the time of death, you :must submit documentatfon of a lawful :right or claim. Date Signed: FOR REGISTRAR`S USE "ONLY Signature of Applicant: Momr, ua veer (Photocopy ID amd attach foapplication form) 06 20 2013 Type of 1 D: ~' ~ Driver License i v Address of Applicant: Issuing state; Anthony J. Calabrese Expiration date.: (Applicant's Name) N,u'mber: ^ Other iD„ Specify 1028 Main Street (Street) N"Umber: Fishkill NY 12524 Type; (clryi (ware) (zlpl Number: Telephone No.: ( )(845) 896-6166 Type: DOH-294A (06!2005) c~T, ~o~EZt c~{. ogue~imooc~~ ~ur~EZaC o~omes., .~ize. ESTABLISHED 1829 1028 MAIN STREET FISHKILL, NEW YORK 12524 845-896-6166 To Whom It May Concern: 900 ROUTE 82 HOPEWELL JUNCTION, NEW YORK 12533 845-221-9234 June 20, 2013 Please be advised that we are filing the death certificate of Robert Myers, who died May 31, 2013 late due to the fact that he had no family and we had to wait for court papers in order to proceed with his burial. Copy of Administration papers enclosed. Anthony J. Calabrese 06/18i'2013 11:07 8d54~i60681 PAGE 02 Certificate# 24703 Surrogafie's Court of fibs Sfiaifie of Nevin York Dutchess County Certifi~afie of Appointment of Administrator File #; 2013473 iT IS HEREBY CERTIFIED that Letters in the estate of the Decedent named below have been granted by this court, as follows: Name of Decedent: Robert Myers Date df Death: May 31, 2013 Domicile: Fiduciary Appointed: Mailing Address: Type of 1_etters Issued Letters Issued On: Town C1~-Wappingers Fa11s I~amela Barrack 22 Market Street Poughkeepsie NY t 2607 I_ETTERS~ OI` TEMPORARY At7MINlSTRA~"I'4N June 1A~; ,2013 l:et'ters Expire dn: DQCember 14, 2013 Limitations: TWE LETTERS ISSUECS. BY-fi.H~ Ct1UR7`SH#L!, REMs41N IN FWI_L FORCE AND EFFECT FOR A PERIOD DF SIX Mf31J~THS FRi~M THE ia~l~TE GRAN7'EC>I:ANb, I~SU~D .BY' TFfE COURT. and such Letters are unrevoked and in full force as of this date. mated: June 14, 2013 -.:, IN TESTI11aTGl~IY WWERE~]F, i have hereunto set my Land and~.afFlxed~ the seal of the Dutchess County Surrogate's Court at Poughkeepsie, New York. WITNESS, Hon. James d I'agones, ,fudge of the Dutchess County Surrogate's Court, . ~ ~~ Erica S. DeTraglia, Esq, Chief Clerk Dutchess County Surrogate's Court This Certificate is Not Valid Without the Raised ,Seal of the Dutchess County Surrogate's Court Town of Wappinger 20 Middlebush Rd Wappingers Falls, NY 12590 (845) 297-5771 RECEIPT #57612 07/02/2013 Delehanty Funeral Home 64 East Main Street Wappingers Falls, N Y 12590 Received $ 40.00 for Cert. Copies -Death, on 06/19/2013. Thank you for stopping by the Town Clerk's office. As always, it is our pleasure to serve you. Christine Fulton Town Clerk 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 De ased iC.e.~1~ e,~ ~, ~c~-~~e~~~e First Middle Name of Fa he1r^of Deceased I l ~ I I ^ ~Q ~ ~~~ U ` ~'CT~ltf/ First Middle Last Date of Death or Period to be Covered by Search ~~ 12~2~t~ Social Security Number of Deceased ~~ ~ - t ~- ~ ~n~ Maiden Name of Mother of Deceased Date of Birth of Deceased 11 11 ow~.e.S 1~2~- V1~r ~c~ Middle ~ Last Month ~ Da ~ Year Place of Deat ~ ..~ p ~1 y ~l~a~~a-~ R~ ova. ~~~o~~ +-a- Z LS, nn1 t 25 Name of Hospital or Street Addres~ Village, Town or City Purpose for Which Record is Required 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 `~~~ `~ Date ~ ~ / ~ ~ f Signature of Applicant ,, p ~ Address of Applicant 1 ~~ ~ l~ /+~ iu S ~"`~ 1~'-~-- 1W" ~' `~ ~ ~v Number of copies requested with confidential cause of death .._ Number of copies requested without confidential cause of death Name ~~ ~ ~ ! Address Cry ~~~,~ Ub,~ State N~ ~..0 ~ Zip Code DOH-294A (6/2000) ~ n V.1 \~ Application to Local Registrar for Copy of Death Record /S ~ ~v~o ~ nay. l/zA N~~~~~ cc ~=~~'i~~ ~gfiF c s•~z. ~3 L fo9~' `~<c... ~~ _.. IS ~" ~ ,_ I~ ~ ~ ~~~~~~~ ~ ~~ ~~ ~~ ' J ~ iv ~ ~'u "'=3 7 . ~ ~~ ~r~ ~ '°~ ~,~' -~ 4 i ~~~~~~~ a~a • X88 3sw / /LANtG r C~pMP,BdL /076 /h~.as~,~ ~t~- a T~~oN,~r vtss~~~+ .` Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marria a Record Vital Records Section Search and Certfication Fee $10.00 Search and per copy Certified Copy Fee $10.00 Per copy A Certfication, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. ^~.~ PLEASE PRINT OR TYPE Name (First (Middle) (Last) Name (First) (Middle) (Last) ~ ~~~ ~ Groom !i- -~7 of Bride ~ CI'°V ) :~' L ~ ~,' Groom's Age Bride's Age Bid e ~ ~ ~ ~~ ~ or Date of (~l a G ~ Birth / I~ Residence (Cou - ) G .om ~ ~~ ~~' ~ s ~o (State) ~ I ~D ~~ ~'~ Residence (County) (State e d~3~ BLS ~ -~. l f ,~~1~,~ ' > Date of Marriage ff g~ preyq~ly or Period Covered Married, State Name b Search Used at That Time Place Where Place Where Vicense Was Marriage Was Issued Perfom~ed For what purpose is information required? What is your relationship ro person whose record is requested? If self, state `self.' In what capacity are you acting? If attorney: Name and relationship of your client ro persons whose marriage record is required. Signature of Applicant p~ Address of Applicant Please print name and address where record is ro be sent DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) 1 .~+ L. ~J ~' NEW YRK STATE.. , ~'r ', , _ DRIVERr7CENSE ID: 95~ ~ 312'' CLASS D rR{ ~~~ ~, ~11 ~_ K: s-: '~~, £ i i o-z ~, ,'5F$(: f EYES _ E NONE ~//l~ fl NONE l9SUEQ; TO.1&10 EXPIRES 10.28-18 oMawaesu 1 . ,, i, 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 Cert'rfication. Please do not send cash or stamps. Na of ceased Date of Death or Period to be Covered by Search -~ ~~~ ._ rst ~ ale Last ~ ~~~ Naf~~f Fat er of Dece d i~~~~~ Social Security Number of Deceased First addle '' Last Ma Name of Mother ceased Date f Birth of ceased Age at Death -~ first addle Last th Year Place of D th ~~/,~ 1~ ~ ~~ r. ~~~'~ Name of os ita or tree ddr ss Villa ,Town or C' Coun Purpose for Whi Record is Required What was your relationship to the d ased?~ ~ ~ ~ ~ ~ In what capacity are you acting? If attorney, name and relationship of your client to Signature of Applicar Address of Applicant ~~ ~ /fir -- - - Date_~N Number of copies requested with corfidential cause of death Number of copies requested without confidential cause of death ~ , State r) t.~ Zip Code Name Address _~~ City ~~n, 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 ANO ENCLOSE FEE FEE: Si0.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PRINT OR TYPE Name ece sed ~~ // Date o f Death or Period t`o be Covered by Search l~ ~~J l~ / / / Firs Middle Last Name f Father o~ceased //,(nC/~ `~ / ~/ Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date o f Birth of Deceased Age at Death First Middle Last Month Day Year Place of Death~~ ~~~~ /, /~ ~~ tp~, C// / , /~i~~/ Name of Hospital or Street Addre ss ilia .Town orr Cit County 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 ~ D /_ - ~~~ Si nature of A licant ~ 9 PP / ate / ~ ~ ~ Address of Applicant < / ^ - . COMPLETE FOR DEATHS OCCURRING AS OF JANUARY t 1988 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) • u~ o ~ ~ ~ ~ ~ ~.?.~~ in .. y ~ ~ ~? o ~ f' ~ Q ~ ~ ~" ~~~ ' u. V~asi > cC .• L~ ~Q Ci us r..+ ~ r .. ~~; V W 2 ~~+ X Cr '' N N~ O G) ~~ W 1 O ''K tJ) U ~ fL ~'~ `'l3 to ~ ~ ill F~.. ~. h ~ ~~ ~w~~~. ~.~ ii. ~~~ ~~~ ~ ~~~ r cA ~.. ~ y. .. W_" ~ ~1 ~J ~ ~' W F- ~ ~ ~~ ~. W~~ ~ ~ ~ t. ~' W~ ~ W W~Qid ~ CC~Wa 2 ANEW YORK STAT .. DRIVER~=.~.ICENSE tD: 298-,299 755 CLASS D w .~t?ONTIDE3 t.,w ~ ~ , -a,. N~Ci ._ ~ OT ~ S ~. Fl ~~ ~ t~; :03-0 ~; ~y , , ' E.'NbNE ~?_ . F ~ Vi %f~dt rfil- L e; R ISSUED, 03-05-13 D(PIRES. 03-Q3-21 cam5xr~gfrc w4 .,. f :°tia ' +~ ~ ~ w- . > ~' t ~ ~ ~ .i3 ~ ~ +. ~ r ~ tdu :~ ~~ ~ ~ ill ~~. _ w , ~~ ~ /vim~ ~ ~J ~~ ~ ~ ~~ yy +1i .L.. +s •.~ ~ R t~ry ~-~# 'Y ~~ ~j ~ ~ ~ , MJ -'~ ~ e r l ~;. ~ M ! Zia ~; ~` ~ ~ ~ ~> H.'t.. ~? y ~ , 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 Cert~cation. Please do not send cash or stamps. :; Name of Deceased ~v s CC~-~1cQe s S Date of Death or Period to be Covered by Search ~; ~~.~,,, ~ ~ cis ~ ~~ 1 ~ I ~ `~ First Middle Last Name of Father of Deceased ~q Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Da f of Birth of Deceased " ~ ~ ~ ~, ~ ~ Death Age a t~ ~ - (o ~J~GSG~ > / ~ ~ First Middle Last Month Da Year CJ PI ce Death ~ ~/~ ~' s S ~ (~ ~ t Name of Hos ~or street Address Villa ,Town or Ci ~ Coun e d Purpose for Which Record is Requir / ~ 0 What was your relationship to the deceased? ~~~ ~ (;U~ i 2 In what capacity are you acting? If attorne ,name and relationship of your client to deceased licant n a of A Si Date_ pp g Address of Applicant ~ ~- I7U ro~~ {~~'~5 ~ _ ~'/C'l~f!' ~ ~~~~f ~ r~ l ~ ~ Y~Y l Z~-SG Number of copies requested with coM'idential cause of death '~ Number of copies requested without confidential cause of death Name r ~ C~~~ ~ ~ _~Q ~ Address " I ~. -.iU ry'1'1`I [~X ~ ti~~ 5 cityl•l~hn~V~ ~ « tc, ~~S state NY zip code 1 ~ .~~ ~ DOH-294A (6/2000) ..r' ~~J }D: ~6 ~1 36~~`~ CLASS D '{~-. `~. i _ -, ~ ~ ~. : os- ~~ E• ~~ ~, x. 0~.2~-ro eta .fie-zz-~e ,u~~ h Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section :;... ~::. :::. .::............:........... ~P.C4;~ .... FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name of Deceased ~ a ~ 2 k G Date of Death or Period to be Covered by Search a5 eor~e. ~ ~ First Middle Last o Nam of Father of Deceased M ~ k~ Social Security Number of Deceased Q ~a Z hQr'(GS First Middle Last ad a~ G ' ..3 Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~~a<, Q R~.y ~ a 5 ~ ~ ~ ~ 93 a First Middle Last Month Da Year ~ ~' ,~92r5 a~ll5 Place L, ~C~ h L-GL(~le.. `~" `~`1 ~u~-~h~ss Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required ~ Q ~ r7~ ~ ~ r the G~ O 5 t ~ n r~l L! S ~. What was your relationship to the deceased?_~~b ~~ ~ ~ In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Date ~ ~~~~`_~ v Address of Applicant ~ ~ 3 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 I o~~Y~ M~CABE & MACK LLP DAVID L. POSNER ELLEN L. BAKER SCOTT D. BERGIN RICHARD R. DuVALL LANCE PORTMAN RICHARD J. OLSON MATTHEW V. MIRABILE KIMBERLY HUNT LEE REBECCA M. BLAHUT SEAN M. KEMP .JESSICA J. GLASS CARLA S. TESORO BETSY N. GARRISON DANIEL C. STAFFORD MICHAEL J. CARROLL ANNE B. LETTERIO DIRECT TELEPHONE. (845) 486-6832 E-MAIL. k1f8V0f O~JfllCCf71.COfT1 October 18, 2013 Town Cierk Town of Wappinger 20 Middlebush Road Wappingers Falls, New York 12590 Re: Estate of Robert Myers Our File No. 13250-0058 Dear Clerk: ATTORNEYS AT LAW PHILLIP SHATZ J. JOSEPH McGOWAN ALBERT M. ROSENBLATT THOMAS D. MAHAR,JR. 63 WASHINGTON STREET RALPH A. BEISNER I POST OFFICE BOX 509 KES VL.TRAVER POUGHKEEPSIE, NY 126Q2-(1569 - l-ELEPHON F: (84~) ~H6-6800 MICHAELA HAYES,JR (Retired) HAROLD I_. MANGGLD (Retlredi FAX: %84~) 486-?ti21 JOHN E. MACK (1874-195A) wwW.mccm.com JOSEPH A. McCABE (1890-1973) EDWARD J. MACK (1910-1998) JOSEPH C. Mr.CABE (1925-1981) Please be advised that this office represents, Pamela Barrack, Temporary Administratrix to the Estate of Robert Myers, who died on May 31, 2013. I enclose a copy of the Certificate of Appointment for Pamela and a copy of the decedent's death certificate. I further enclose a check made payable to the Town of Wappinger in the amount of $20.00 which represents your fee for two (2) certified Death Certificates for Robert Myers. At this time, we require a certified Death Certificate to be filed with the Surrogate's Court and a certified Death Certificate to liquidate the decedent's personal bank account. A pre-addressed stamped envelope has been provided for your convenience when returning the certified death certificates. Please do not hesitate to contact me or my Paralegal, Ana Valencia, at 845-486-6826 should you have any questions or concerns. Thank you for your kind attention. 1'ery truly yours, McrABE & MA K LLP KELLY L. TRAVER KLT/alv Encl. cc: Pamela Barrack, Administratrix 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-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: Thomas J. Fitzpatrick 090-72-6293 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: -'09/18/2013 06/24/1977 36 From ' ' To mm / dd / yyy Maid~~:.Name of Mother of Deceased: Death Certificate No.: (lfknown) Dorothy Mahonski First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (tfknown) John S. Fitzpatrick Sr. First Middle Last Place of Death: 24 Regency Drive Wappinger Dutchess - Name of Nospdal 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 5 confidential cause of death copies requested 5 Purpose-for which Record is Required: What is your relationship to person whose record is required? Need death certificates with amended cause of death Funeral Director In whit 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 lawfu'I right or claim. Date Signed: Signature of Applicant: Mer,+h Da Year FOR REGISTRAR'S USE ONLY (Photocopy ID and attach to application form) 10 25 2013 Type of I D; ^ Driver License ' Address of Applicant: isst.ring state: Anthony J. Calabrese Expiration date.: (,appii~anr~s tvame) Number: 1028 Main Street ^ Other JD, Specify fStreet) Number: Fislikill NY 12524 Type: (City) (State) (Zip) Number: Telephone No.: ( ) Type: DOH-294A (0612005) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section FEE: $10.00 per copy or No Record Cert'rfication. Please do not send cash or stamps. ::.:: .i. Name of Deceased ~ ~~"c'/l~ `~'~ D ' Date of Death or Period to be Covered by Search . ~L Fr lL ~ z v/ 3 ~-~~ 2 3 First Middle Last ~ of Qeceased Na Social Security Number of Deceased ~~~~~ First Middle Last Maiden Name of Mother of Deceased r2~ ~S Date of Birth of Deceased / 8 J 9 `~~ Age at Death o ~~;~.2~~/r/~ Sri/ S ~ Z First Middle Last Month Da Year Place of Death Name of Hos ital or Street Address Villa ,Town or Ci Coun Purpose for Which Record is Required ~, pD Ji/ D ~ l>CCG~l ~~t/% I-~ T /~~~ ~ O~TiS~~k,~ ~~/~/~l/~;"S~%Eh/l"- What was your relationship to the deceased? ~ US S'r~~'-U In what capacity are you acting? i`/~~~t~D 6'~ D E'c ~ ~ S ~ /~ If attorney, name and relationship of your client to deceased /d Zee / 3 G~ ~ G Date Signature of Applicant Address of Applicant ~ ~ ~~~~~~ L Dr('/ ~~ ~r/r~i~F'i~'C ~'S F~1 L tir /Z$~`I Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name Address City State Zip Code DOH-294A (6/2000} ANEW Y~~RK STATE P< r. }~-~, ~ ~~ DRIVER. LICENSE i ~ ~~~ ~ I D: 33~ X76 098 CLASS D ' r,~ec4 ~, ~A1:Fft~],d dF4 i4F~#AS~il;ikV N6R,S~LS'PPY 1258U 0&05+8 sec: M EYES fit. Kr s-10 E NOME ~_ ~,~~~ ~ R. NQNE ~ 7SSU~: 02-1&13 EXPVRES 0&05-21 Nv1o~leroM r ~~ 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 Cert'rfication. Please do not send cash or stamps. --_._ Name of Deceased Date of Death or Period to be Covered by Search ~d ~~~ C~~"~--~ 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 ~~ii'§t U( ~/~ Middle Las Month Da ~ Year Place of Death Name of Hos ital or Street Address Y~/~' Purpose for Which Record is Required Town or What was your relationship to the deceased? G,~~f In what capacity are you acting? If attorney, name and relationship of your client to deceased Signature of Applicant Date~~~~~1 ~ Address of Applicant f Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) Applica~tio~n ~o Local l~eg!Istrar NEW YORIt STAI-L~ DEPAI~TIVIENT OF HEALTH Vital Rccor~ls Sc.~clion '~O~' C~ df ~~~",~ ~~c~~'~ NI.~ASE COIVIPI^ETE-FORM AND ~NGL~C7S~ FED--,--~ „, FEL: :G10.00 I.~er copy or No Record Certification. Please do not send cash or stamps. ___~ _ ~. PI*~A~~ PFi1NT OR TYPE _ -~ .... . ,. NarnE ni C~ecc~asecl L_~ i s ~ ~arv en ~ Sr- .pate of Doath or Period to be Covered by Se <rch . Frost Mi~lillc Last 4rt ~I ~ 13 Nanrc of F::,tlu:r of I:)c,~r..eas:d Social Secr.irity Ni.unber of Deceased f=irst __ _ Middle Last Maiden Name of Molher of Deceased Date of Birth of Deceased Acd at Death ~ I vY,o• ~~h ~ ~~ . IZ , ~°ISS S ~ First !~ Middle Last Month Da Year Place of Dc~alh ~ F`~ ~ co~.~(M~ ~t~ ~~ ~~t v~~ ~ ,~S v Name ul Hen ~it~rl or Stroet Address it aqe own or City C .unty Purpose for Wlurh Record is Required C--~ d~ Lr~ f~trtul~ Wlrat was your rclationshil.~ to the deceased? ~~-1 ~(~~- In what capacity are you acting? UYl ~c~ c+~ ~+It~ - - _ ~ If attorney, Warne ~-~nc ~ ~ ionsf-ip of your client to deceased Signature of Applicant - --. _-~ Date I ~ " `1 - 13 Address ul Applic.~rnt -_~~it ~ ~ IP~~{~r ~~'~ ~ ~~~ Ny ~ZS~~ CaIVIpLETE FOR DEATHS QCCURRING AS OF JANUARY'1. 1988 ---~Nu~r~tx~r of copies requested with confidential cause of death Nurnher of copies requested without confidential cause of death N~~.ASk t~f~INTNAM~'ANG1 ApR.R~~S'WHERIl.R~GOFip SHUUI»p B~ S~IVT Name _._ _ . Addi ess 'City _-_ __ _ State Zip Code cool-I-.>~a~A it~~zoool U:~D~- Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section _ PLEASE COMPI..ETIw FARM AND ENCLOSE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. 'PLEASE PFt1NT OR TYPE _ Name of Deceased Date of Death or Period to be Covered by Search T'EREsA L~1~JITF~.E ~/ o C% 31, aol3 First Middle Last Name of Father of Deceased Social Security Number of Deceased First Middle Last ~ 83~ ~~ - ~fS~ZG Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death L YD~q Fi (UrJ~N~ / / /'~~3 ~6 rst Middle Last Month Day Year Place of Death .EL/fNT AT Lzl~~/'J~rNGC~QS GFjLC.S W/3PP!'n/~E~ps /=~jGCS .DUrGH~55 Name of Hospital or Street Address Village, T-er-eity County Purpose for Which Record is Required `TU S E TTL L L S TR Tom' What was your relationship to the deceased? /=c>n/ F„~G J7 !/ZEG T6~t' In what capacity are you acting? Sgnrt If attorney, name and relationship of your client to decea sed Signature of Applicant ~ Date ~~- `f - /'3 _ Address of Applicant ,- ,~ ~~~ COMP~,ETE'FpR DEATHS OCCURRIIyG AS OF JANUARY 1 1 -=~ Number of copies requested with confidential cause of death ____ Number of copies requested without confidential cause of death RLEA Name Address city - R~ iQULt? SE SENT DOH-294A (6/2000) State U~ Zip Code A~pl6ca~tion ~o LocaM IReg~str~-r NEW YORK STATE. D[:_PARTMENT OF f-IEALTN Vital Recorch> Seclir'I~ ~~~ Co of Dea~~ h Recor+~ PLEASE CQIUIPLI~7E'FORM AND ENCLOSE FEf , '~"--^"'"'-'~""'",,, rEl~.: :x;10.00 per copy or No Record Certification, f Ie;ase do not send cash or stamps. _ ---- - PI.EAS~ PRINT OR T`fPE _ _ - -- Nan~e of n~ i c.~a~;c~d .Dale of Dearth or Period to be Covered Uy Se~Irch Sir C • Corwin = ~~,~ . ~ , 7~ `,3 t lr`~t _ _ Mirlrllo Last Narn~~ of F.:rther of DocoraserJ Social Secr.Irity Nurnf~er of Deceased ~o Co~lOr I=u~~t T____ ~_ Mlddle Last o82- 3~ - ~~~ Malden Narnr, of Moilu.r of Deceased Date of Birth of Deceased Ag ; at Death C-rcrFw~_ ~~~ t- ~a~ rq I~~t I ~ Z First,^~ Micli~le Last , Month Da Year Place of Death (pcy-( `~ ~r(tbtiq ~Ci~ N f H i ~~~i .~J~ ~I5 ~-- ame o osp l,~~l or et Address ~ Town City Cc unty Purl:,osc for WIiICII Record is Required ~ (~ ~(` L--i\C- ~ T~ 115 What was your relationship to the deceased? ___ ~ ~-~~ ~ f eG~21Z In Whdl CdpdClty aro you acting? ,~~___ ~~~ ~ ~-_y~ It Lttfomey, Warn ~ ~~lationslrip of your client to deceased Signature c;f Alrplicant -___.-- -- Date ~~-~ _ 13 Aclclress of Applic~ult _~~~___~_o~ ~ 1 ~~ T 7 __T..~- GOIUtNLETE FQR DEATHS QCGl1F~-RING AS ~F JANUARY'1 1'88 ~Nurnt,er of col)ies rcgraested with confidential cause of death I __ ____ Number of copies requested without confidential cause of death V` Dol 1 ~~-I~e fis/~~oool Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Death Record Vital Records Section PLEASE CQJVIPI,ETE FARM AND ENGLOSE>FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. PLEASE PF21NT OR TYPE Name of Deceased Date of Death or Period to be Covered by Search First Middle Last Name of Father of Deceased Social Security Number of Deceased UNc;6ir~~NABe.E //D_ tf~} _ O1Z.y' First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death First Middle Last Month Day Year Place of Death E~l~ nl T .4T W l~ P+" ~~GFRS FG5 W~PPjMGc2s Fflu-5 ~1~c~CN~55 Name of Hospital or Street Address Village, T~et£fty County Purpose for Which Record is Required j v SE7T~E ES 7,9T~ What was your relationship to the deceased? FUhI ~2AL .~~ 2Ec T D.C In what capacity are you acting? SArLrC If attorney, name and relationship of your client to deceased Signature of Applicant ~~~~~r~. ,d1~O,~~~~ Date /'~- ~ d -!3 Address of Applicant _ ~~ L--. /y1Al~t1' S' ' 1 a ~,~~ lnlG-E><S ,~i3~~s n/ ~ / ZS; o GOMPI„ETE FQR DEATHS OCCURRING AS OF JANUgRY 1 1988 -~' Number of copies requested with confidential cause of death __ Number of copies requested without confidential cause of death PLEASE PRINT NAME AMD ,4DDRfTSS WH)>kR'~ RECORp ~HOUL.fJ BE SI~NT Name F Address __. City _ State Zip Code DOH-294A (6/2000) Application to Local Registrar NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Qeath Record Vital Records Section ,: ', FEE: $10.00 per copy or No Record Certfication. Please do not send cash or stamps. ::::. :: .:.. Name of Deceased ~~~~ Date of Death or Period to be Covered by Search SG~a~ 1t-23-Z~t3 First Middle Last Name of Father of Deceased Ar ~~ ]~ C~ W Social Security Number of Deceased ~A-nZC~vr n ~tnl<~~~~ ~~ First Middle Last - Maiden Name of Mother of Deceased Date of Birth of Deceased t~1~~ Age at Death .3a,~~ -1 ~n O~ an zoo ~ t~ ~~ ~t3 ~ First Middle Last Month Da Year to~~~ Place of Death t 5~0 TL©~~. 37b W ~ippr~,~~ers Uktr~~ Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose #or Which Record is Required ~aw,~lti ~~e ~t~~ eased? ~" c e -What was your relationship to the d ~'~(~-~ ~r('{c~d~ 1 - ~ In what capacity are you acting? I`~^~ ^-L12~r ~l ~f<<~~ If attorney, name and relationship of you t to deceased n r clie ~~ ~ ~ ~~~"' ~~ "~~~ i Signature of Applicant Address of Applicant ~ ~~ ~°~~'*` Pa ~ ~e~ Date B ~ ~ ~~ g~ dU o~~ ~ ~ `~, ~ (~ 4'3 Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death Name ~cl~~C ~~~~Z~1 ~~IM>! Address ~ ZS Svc l~~d-a,t O~ .~.{~ ~ City ~~al~~~ CfJ/~ , 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 PLEAS' ~OMI~LETE Ft3RM AND°ENCLf,~SE FEE FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Pf::~ASE~:PRtNT QR TYPE Name of Deceased Date of Death or Period to be Covered by Search Clementina DeMatteo November 17, 2013 First Middle Last Name of Father of Deceased Social Security Number of Deceased Arthur Loreto 125-10-7960 First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death Angelina Antenucci Apri129, 1918 95 First Middle Last Month Da Year Place of Death 13 Balfour Drive Wappinger Dutchess Name of Hos ital or Street Address Vitaa e, Town or Cit Coun 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 November 18, 2013 Signature of Applicant Date 895 Route 82 Hopewell Jct NY licant Address of A pp ,._ ,: . ..F - IF:. 1 :1:9i8a,t ~ ,. :.: Number of copies requested with confidentiat cause of death Number of copies requested without confidential cause of death Name _ Address City DOH-294A (6/2000) State Zip Code no~~~ b~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section FEE: $10.00 per copy or No Record Certification. Please da not send cash or stamps. Name of Deceased (.ou 1 s ~j~~l-~s ~a,U.s~ian~- First Middle Last Name of Father of Deceased L.i7U~~S ~c~S~7~c% Si: F' t Middle Last Date of Death or Period to be Covered by Search Social Security Number of Deceased irs Maiden Name of Mother of Deceased Date of Birth of Deceased Age at Death ~4 ~l%ld', J~wc1 S'a. t-~ d-e r ~ i - o? ~ - l 9 37 S.~" First Middle Last Month Da Year Place of Death - ~'/~s N ~ (,~'G/"/PSS L l rc~e` ~r~ (/ f ~~ l hG~r.s ~ ~ Coun Villa e, Town or Ci Name of Hos ital or Street Address Purpose for Which Record is Required What was your relationship to the deceased? "Fa'~ /" In what capacity are you acting? If attorney, name and relationship of your client to deceased Date ~~ " ~Z ~/3 Signature of Applicant /~ ~rf Address of Applicant ~r.~~~~~r/ /~ ~~~ ~~- ~ n ~~ ~~'~ ~~~~`r ~ ~ ~ /asg~ Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000) ~ ~ l I ~ / J Application to Local Registrar for Copy of Death Record EJV 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 Certfication. Please do not send cash or stamps. Name of Deceased First Middy Name of Father of Deceased First Middle Maiden Name of Mother of Deceased First Place of Oeath Name of Middle or Street Address ~ Purpose for Which Record is Required What was your relationship to the deceased? Town or Age at Death In what capacity are you acting? If attorney, name and relationship of your client to deceased Si nature of lirant ~ Dat 9 P 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 S r ~ ~©~c~ DOH-294A 6 2000 ~ ~ ~c ~ _ .~ 4 Last Date of Death or Period to be Covered by Search Social Security Number of Deceased Date of Birth of Deceased Last I Month Day Year Zip Code 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 Certfication. Please do not send cash or stamps. .. Name of Deceased ~ ~~~ Date of Death or Period to be Covered by Search ~rN~7~b ` ~' 7 y First Middle Last N of Father of Deceased ~Lvp Ta ,~~ /~~'~' Social ecurity Number of Deceased First Middle Last Maiden Name of Mother of Deceased ~} C v~G~ ~ v v ~ Date of Birth of Deceased , y ~~ `~ Y Age at Death , i , i ~~ First Middle Last Month Da Year PI ce of Death ~ 3 A ~ ~ A ~~ ~ o ~2 ~ v~~ G~ K/E C~~~ir''9-r%~ ~~ ,f - N ~ LJ 1 >'tiT~ ~ ~ O ~~~ /~v~ (/ Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose for Which Record is Required s~~ What was your relationship to the eceased? ~' ~ ~~ In what capacity are you acting? If attorney, name and relationship of your client to deceased ~-- ~ ~ ~ ~ Z' ~ ~,~ Date v` Signature of Applicant v ~ N ~ ~ A Address of Applicant ~ G ~ /~ ~°~ _ o . -Z 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 Record ` Vital Records Section FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ::~:: Nrame of Deceased Date of Death or Period to be Covered by Search First Midd Name of~Fat~her of Deceased ' " ,/~ r `~ ~©~~ ~ Social Security Number of Decearsed ° ~©"'"' ~ ~~ 7 o ~ Middle First L a s f Maiden Name of Mother of Deceased ~ ~...~ ~~~ Dat~e~of Birth of Dp~eceased 0~ ~ ~ Age at~jDeath ~ Middle ~irst ear Month Da C Place of Death ~ P ~~ L A~/~ ~ ~~~~~5 ~ ~~~~~~~ me of Hos ital or Street Address N Villa e, Town or Ci Coun Purpose for Which Record is Required -What was your relationship to the deceased? ~~~ ~l 'l ? ~G~IG ~~~ In what capacity are you acting 3 .. If attorney, name and relationship of your client to deceased ~i~G~!~~`~!/ ~-, ~_ Signature of Applicants ,~ ~~ ~ ~ ~~~'~ ~~/'~ ~ Date 1~~~~ _ ~ ~ j ~ y 1~ „~ 1 "~~K 7 ' Address of Applicant ~ ., Number of copies requested with confidential cause of death Number of copies requested without confidential cause of death DOH-294A (6/2000y ~~~~a~a~tMOr~ ~~ Lc~c~t~ I~~g~s~r~r MEW Yc~~ tl<. ~~ l Ari-' t~l~_1~,~~~-rlvthlv~r car- l-l~~L-f~l-i ~{. ~+ ~^~, y..,,, ~j Vit,,l f=t, ~ „~ I~> `~cv:lir„~ li~~ t..~~ ~~ 1.J~'~ ~:11 1-11~~.+~~~ ~. -:, --- __-__PL~,4~1: CC]IW11~L:~Tk FOf~M ENO ~N4l~COSE FCC..°~, ... .... , ,-T-~mm,-,.-,.m. f=l:_1-:: :I, IO.i)0 pcr col,y or No Fieci~rd Certification. F'l~rase da riot send cash or damps. l~~d~rrnc: ui 1~~~c, , ~,rl ___..~ , N ~h Y-u `~l ~IVliriill~~ I~~ltrtn~ of F ~Uhrr ul Dr r r~~r~i~d T~~~h ---_ __ _._.__ P ITk~A ~ k P 1~ t N ~I" Q F~ C Y P F _ -..-'-~-.-_~, D~rle al D~~=rll_i or Period to Ue Covered Uy S such Last ~Q~~~d I-rr~l iVligtlle L_asf Ivlcuden tVtarnr::~ Uf IVlntl~uir of Dc;ceUSed - ~~ Naln T~~ 1 la Fi,~.t ~ IVliddle Last Place of D,_rrrlh Y~t:uru~ of 1 Ir~sl~il.,l or Stri~at Address Social Security IVrintber of Dec.easecf^ Date a1 13irtlr of Deceased A Ca at Death Co -Ot - Li °~ ~ ~~ Month Dav Year ~~ 1 V`~ u City ~~~~ C:r•u Vilt ~'urpo~~;r~ for VVlriclr 1==tc~cord is 1~~(oquired L'*~ ~~ ~ Vvh<al Wit[.; yUlll r~.~l~ati,:,nslril~ to [Ire deceased'?--_---._-- -__._- --___.--.--__-____ ~-~`-~ I~, tiulr~rt c;~y,~:ualy .:are r.,r.r ru:Ung,? ~~ 1 __(~ ~1 - _-------------b~~r_~l~ ----° T- -- It alturr,oy, n~une ,~rnr ,: ~ stop o~ your client to deceased Siynalra~~ ul Aly:,lic,.',nt Date-_ ~ ~" ~q ._ ~~.______ _- -,-.-_ _ :: _L,l~lu-r'L~k_l L f=C~li D~ATI~IS (aC:CUI~RIIVG AS Of JANI~AE~~f 1, `1.988 ~u,r~l,r~r of r:r~l>res r~~r~lu~sicad with confide~nti~al cause of death _ ___ Iv+rrr~l,r~r ~:,( CUl;il'-, reduc:~slcd wi~l,ocrt con(idenli~rl r..ause of death - - __ _ __ .----- ---_ _~._....:^Nr, M ,~,~k_ I~t~lt~ f CVt?.IVI~ ~1.N~ AR(~Fi~~S WH~C~~ I3~G0[~p. SHC?l,fl~Q E3~>S~IVT I'~drri' Addra~~s City _ ___.__. _____ -- Slate Zip Code _~ 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 Certfication. Please do not send cash or stamps. Name of/D~Qa~ ~ j~ C ~ ~ Date of Death or Period to be Cove by Search First Middle J Last Name of Fa r of Deceased Social Security Number of Deceased Mrddle La~~ First Mai time of M er of Deceas Date Birth of ceased / Age at Death /!!/~~ First Mrddle Last Month Da ~~'ear Place Death ~ L~~~/~~, / Name of Hospital or Street Address Villa e, Town or Ci C~un 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 ~~ I Signature of Applicant Address of Applicant _ Number of copies requested with cont'idential cause of death Number of copies requested without confidential cause of death r DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section __ :.. FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. Name eased ~ /,/////)~ Date of Death Period to be Covered by Search i7s~' Middle Last Name f 1t~~th of Deceased / Social Securi N mbar of Deceas ~ J, jl, //~~ ~~ First Middle Last Maiden N of Mot er Deceased Date, B"rth of Deceased Age at Death //`~ ~ Month Da Year rst addle Place of Death ~ ~ ^ ~~ /, ~ ~ ~ ? ~ ~~ o~ ~~ Name of Hos ital or Str t Add ss Villa o Purpose for Which Record is Required -What was your relationship to the deceased? In what capacity are you acting? If attorney, name and relationship of you to I Signature of Applicant Address of Applicant _ Number of copies requested with confidential cause of death Application to Local Registrar for Copy of Death Record Number of copies requested without confidential cause of death DOH-294A (6/2000) NEW YORK STATE DEPARTMENT OF HEALTH VITAL RECORDS SECTION Application to Local Registrar for Copy of Death Record Fee: ,County Distric# -$.3.0.00 /'Other Districts -'$1.0.00 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 i## 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: -0R- 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: Kenneth T. Orzechowski 098-34-2828 First Noddle Last Date of Death or Period to be Covered by Search: {mrnfddlyyyy) Date of Birth of Deceased: Age at Death: 12/08/2013 12/31 / 1942 70 From To mm / dd Maiden Name of Mother of Deceased: Death Certificate No.: (Ifknflwn) Eleanor Kara First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (It known) Unknown Unknown First Middle Last Place of Death: 3 Pembroke Circle Apt B, Wappingers Falls Name of Hospital or Street Address Village, town or city County Number of Copies Requester!: (For deafhs occurring as of January 1, 1988 specify with or without con~dentia/ 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 you are not the parent or child of the deceased ar the spouse of the :deceased at the dime of death, ,you must submit documentation of a awfu''1 r~€ght or claim. Date Signed: Sign ur of Applican . Mon+r, da vaa~ FOR RE16'ISTRAR'S USE 'ONL'Y ~Phatocapy ID and :attach to ~pp6caGon form,) 12 16 2013 Type ~~ I©~ ~ ^ Driver License Address of icant: Issuing stete~ _Anthony J. Calabrese Expiration date; (Applicant's Name) Nurn'bet: 1028 Main Street ^ Otlher ID, 5pecifiy (Street) Number: Fishkill NY 12524 Types (City) :(State) (Zip) Number: Telephone No.: ( )(845) 896-6166 Type:: UUFi-Yy4A (U6/LUUb) l~p~~~~at~ar~ ~~ ~...a-c~' ~~r~isl~r~lr I ILW Yi;l U~ `; I A I-t-' I)i.:F~'~~1=t-I 1U11=NT Ot=- t-IEAL-I'l-1 Uit~_rl 1-t. ~ ,r~1t; ,craiun •~'~~" ~~ ~~ ~~~ ~'.~ ~~~Cl~"C~ w. _ ..__ .__._ _._. __ _ _~._.~Pr..~~aSs CCQIVIh~:~TE FORN'I AND t~NiYa~OSE FCC ' . ;,` .. , ^'""-T-"'""'',"~."""'" 1=L1~: a;IO.Oi) por col;y or No Fiei;oril Certification. Pleasa iio ilut send call-i or stamps. PI~k~Aa~. PRIM' QED TYPkz: I~d~;rnr' ui 1:1C1ix•;;sc';i 1 ~ ~lv~~~b C Dxtc of D~;atl_i or I~eriod to Ue Covered Uy S~~;;rcl; 1~V~.,{" =~ 'J -• i 1 ~ -1'~ `~ ~3 t Nrr.i~I L~;_ t IJ;_utie r,i f=:.illu;r ;~,I Ik, r.c:i,;,~;d _ _ Social Sect.irily N~-ember o~l De:cezlsed ~~~ _ ir•i I Nlirlrlle Last Nle,i~ie IJtari;l~ ;,l Mulher c;l Deceased 1-~~~~t Nlir.l;al~~ Last hloC~: of D~~,:~lh ~ _ N~~uru~ ul I lusl;it ;I or' .;krta~~I /ati[lCfJe_ss F';trl~x;~;e lu; VVlur:h 1=(ocord is F=tedrrired -P.~I-~ol oF- 1 ~ ~ c~ -~---(=n i~YS VUh~t wts your ri:h;Uonsl~il; to the deceased? Date of Birll~ of Deceased A ~:: at Death ~ - , ~ --- 3 ~ -~ Nlonth Uay Year tllar]~Town ~u City Cr aunty I;; what cal~~~iciiy ;ru yur; acting? _ _~(~- ~ 0~,~'~(~'~ ~~'Vi,~, I( attcar,c~y, ~rur;e :~~r;il rcl~rtic~nshil.; of your Client to dece~~ised ~~ ~I~n~rtu;i~ UI Arlrl~ess i;t f\l;plicrrnl Date ~ ~ " ~_._.~ ~ 3 .__-- _-- ---_-_-- .._ .~__~Uiutt~l ill E f=C)f~ C1~ATi-1S C~C:CUF~RING AS Ql JAN~1AiRY 1; `t~88 --~r~~- Nu;rrhr~r r;f rx)l~;ie:. rcrtuestod wi'lh cor~fidi:niial czrt~se o~f det;lh _7-- I~,u~;hc~r o! col.;ics regrtesled will~Ot_It confiiliv'niial cause of de«tll [col - ~'!-;.a~'; ~t;i~wu,r;; ~.~~~~a3 DAVID L. POSNER ELLEN L. BAKER SCOTT D. BERGIN RICHARD R. DuVALL LANCE PORTMAN RICHARD J. OLSON MATTHEW V. MIRABILE KIMBERLY HUNT LEE REBECCA M. BLAHUT SEAN M. KEMP JESSICA J. GLASS CARLA S. TESORO BETSY N. GARRISON DANIEL C. STAFFORD MICHAEL J. CARROLL ANNE B. LETTERIO EfMHIL' 3V82f1C18@fT1CCf11.COR1 December 20, 2013 M~CABE & MACK LLP ATTORNEYS A"f LAVb' 6i W,gSflWlilOiv STRL-E.1 POti"f OFh'IC'1~: 13l))C i09 POUGHKEF.NS1~. Nl' 1:003-OSOv TELFiNH(iNE: (845) a80-0800 FAX: (8451 480-7621 www.mccm.com Attn: Town Clerk Town of Wappinger 20 Middlebush Road Wappinger, New York ] 2590 Re: Estate of Sarwat Lodhi Our File No. 13797-0001 Court File No. 2013-968 Dear Clerk: PHILLIP SHFtZ J-JOSEPH McGOWAN ALBERT M ROSENBL4TT THOMAS G INAHAR. 1R. RALPH A. BEISNER JESSICA L VINALI. KELLY I.. TRAVEn MICHAEL A. HAYES. JR. f 2Fliredi HAROLD L. MANGOLD (Petiredl JOHN E. MACK (1874-1958) JOSEPH A. McCABE 11890-19731 EDWARD J. MACK (1910-1998) JOSEPH C. McCABE (1925-19811 Please be advised that this office represents, Mansoor Ahmad and Rebecca M. Blahut, co- Administrators of the Estate of Sarwat Lodhi, who died on November 23, 2013, appointed by the Dutchess County Surrogate's Court. I enclose a copy of the Certificate of Appointment. We are in the process of submitting a claim for a life insurance policy and a certified death certificate is required iti order for said claim to be processed. Therefore, I enclose a check made payable to the Town of Wappinger in the amount of X10.00 which represents your t'ee for the certified dea~h certificates. I further enclosed is a pre-addressed stamped envelope for your convenience when returning the death certificate. Please do not hesitate to contact me or my Paralegal, Ana Valencia, at 845-486-6826 should you have any questions or concerns. Thank you for your anticipated assistance with regard to this matter. Very truly yours, McCABE & MACK LLP Q~ - '/Cft/,~f I lj~.V KELLY L. TRAVER KLT/alv Encl. cc: Mansoor Ahmad, Administrator Local Registrar Fee: 'County District - $30.00 /Other Districts - $10.00 ,.per certified copy ar 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 #orms of valid photo-ID: -0R- 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: Joan M. Mari 121-22-7874 First Middle Last Date of Death or Period to be Covered by Search: (mm/dd/yyyy) Date of Birth of Deceased: Age at Death: 11/28/2013 07/20/1925 88 From To mm / dd / y yy Maiden Name of Mother of Deceased: Death Certificate No.: (tfknown) Mary Agnes Smith First Middle Maiden Last Name of Father of Deceased: Local Registration No.: (ff known) Alfred William Tyson First Middle Last Place of Death: Elant At Wappingers Wappingers Falls Dutchess Name of Nospda! or Street Address Village, town or city County Number of Copies Requested: (For deafhs 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 4 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 chi'Id of the deceased or the spouse of the deceased at the time of deaths .you must submit documentation of a Iawrful night or claim. Signat e f Applic nt: DMotnth'gh Da Yeer FOR RE6iISTRAR'S USE ONLY (PMatocopy ID and attach to applPcation form] 12 02 2013 Type of ID: ^ Driver License ' Address of Appl~ ant: 'Issu rngstate: Anthony J. Calabrese Expratiorn date; (Applicant's Name) N'urnber: 1028 Main Street ^ OtherllD, Specify (Street) N!U'm ber: Fishkill NY 12524 Type: (City) (State) (Zip) Number: Telephone No.: ( )(845) 896-6166 ___..----___-- Type: DOH-294A (06/2005) ~~L/~~I I~ ~ 'C'e`k' NEW YORK STATE DEPARTMENT OF HEALTH Vital'Records Section .;.. . FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps. ..; .....:..::. .:;:.:..:: .:: .::::. -, Name of Deceased n /~7~-~1~ ~- ~ °~C~~ Date of Death or Perio/d to be Covered by Search 3 / 1 ~ First Middle Last i o ~ l 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 Da Year Age at Death Place of Death ~ ~ ~-k y jo~v ~/' ! Name of Hos ital or Street Address ~,.~4~~ ~ ~~ c ~' /~ 1 Villa e, Town or Ci t~c~. ~c ~ mss Coun s Required co rd i Purpose for Which Re ~ J ~ / ' A -What was your relationship to the deceased? ~~ In what capacity are you acting? ~ y~ ~ If attorney, name and relationship of your client to deceased 'i Signature of Applicant -~~- l~~'~'` ~" ~y~ S~ Date / Address of Applicant ~~~~ ~ /~x ~~ ~5'S~1 L/~r~~ / Z~L~/3 ~ Number of copies requested with confidential cause of death Application to Local Registrar for Copy of Death Record 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. Name/ of DeceasIe,d 1~ First Middle Last Date of Death o/r Period to be Covered by Search ((( Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased First Middle Last Date of firth of Deceased ~~Z~~/~ Month Da Year Age at Death Cy ~- l s Place of Death (~ ~ ~ /~o ter- ~ (` !/4~~J"S ~ ~ ~Y ~~7/c~~~S Name of Hos ital or Street Address Villa e, Town or Ci Coun Purpose #or Which Record is Required j'LJ `l S ~ ~ rvc ~i ~ ~~, 6-~ What was your relationship to the deceased? In what capacity are you acting? ~ Y~ P If attorney, name and relationship of your client to deceased Signature of Applicant --~ Address of Applicant ~°-~' ~ ~~~-'I~ ~ s ' Die ~ Z ~ 'L~~ °y v'SP~ y~~ -.~- 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 Rornrds Section Application to Local Registrar for Co of Death Record FEE: $10.00 per ~:.''/t: iii:) rr ~::::::::::.~ •:::. i .:::.........::L::i}ii: Name of Deceased ~rst ~y Middle Name of Father of Deceased copy or No Record Certifica~on. Please do not send cash or stamps. ......::::. ~:::::....,..,.,....,.:: .. ........ .;..t,. .........Y.. $...::: ... .. ~ .. S.w:.a~..:::..:::. .. ..... ..:: i.i .. :............. ./.... Date, of Death or Period to be Covered by Search Last Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Da~~ Birth of ~9eased 7 ~ Age atU-Death First Middle Last Month Da Year ~ r Place of Death / Name of Hos ital or Street Address Vill e, Town or C' Coun Purpose for Which Record is Required ~ Y 5 ~ ~ ,~ ~~ sf.s~,~,~-~ what was your relawtionship to the deceased? In what capacity are you acting? ~ `~ S p _ If attorney, name and relationship of your client to deceased Signature of Applicant Address of Applicant _ Number of copies requested with confidential cause of death Number of copies requested without corfidential cause of death Date ~ ~~~ ~l ~ %z~/ Name _ Address City _ State ~~4 ~~ -- s~° ~~ Zip Code 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. .............................:.......................................:.:..:......:;.....:....,..,.::.... .. ....~v. .>:.: >,:~., i~\i}::•!::!(:':iiriii iii ::v~:i:........~......:.....KSti~~: y - . ' ,.r:: :. :.:v:.:::.:. ....::................::........ .,~::: >~:-> Name ofDeceased /, ~e ~ n ~ l D~ Z~2,~ pw S~Ci ~irst Middle Last Date of Death or Period to be Covered by Search /02 ~~l ~ ~ Name of Father of Deceased Social Security Number of Deceased First Middle Last Maiden Name of Mother of Deceased Date of Birth of Deceased /~ 3 / ~Z Age at Death First Middle Last Month Da Year Pla~ o~ ath ~ ~/ ~ -~C~ Name of FI`osm or Street Address Vil , T or Ci ~ Z S ~? v . Coun Required for Which Record is Purpose p \ What wasyouur relationship to the deceased? ~ 5 In what capacity are you acting? ~ ~, c S~ Cam` ~ - ~~ r' If attorney, name and relationship of your client to deceased S' nature of Applicant "v D~ I a- 18 I - ~9 Address of Applicant Number of copies requested wKh confidential cause of death ~ Number of copies requested without confidential cause of death Name ~ ~ S P Addre's's' I ~ M ~ c~~ ~ ~ , ~t S~ e~ City W ~ State Zip Code I Z c~ DOH-294A (6/2000) I lI w Yi ,I ll<. ~, I ~a rt: nl-F>~,~=~-rNll~-Nr car- t-Ir~a~-rl-I ~`~ I~ ~~,yl:+~c~~ ~N~l"N ~t~ ~.~C,~yc'~~~ry; C~+j~ ~5~~"~~' vil.:,l f-ic ~ ii~~-~_; `~i ~:li()Il 1~1 ~~ ~~ ~4G~~:11 I~lll-~r~~~ T~,...~,_._ ,~_ - - ---- ------ ---~--PL.~~~I~ CC~IV16~1~.:~rk FC~Rfyl ANO_~IVG.I~os~ FC~...',:~--~-~„_._ -,-,_,_.r,.~,~,,,,,....,,~,,,~,. Ilk: :I; 10.00 per col,y or Nu 1=ieeord C;rllllcation. Phase da r-rot send cash or stamps. - - __- -,- ---- __ . _ __ . _...__.. __ ___ __.__. - ,~ h~~~~ ~ h h_R I N 7 Q F3 I Y N ~ _ N:un~ u+ I,ec, ~ rr`I .Date of Dr.,r[h or I~eriod to be Covered uy S. ~~rch I u:il IVII,.iiNcr I_.ciSl ~ 1 ' ~I ~ ~~~ I~~<:,IrrL c;l (~,thc:r u1 I )C'1:~'ilsC'lf ~~~ I=i~ ~: I M~~~. ~- iVUq,-11e L~,s f IVlar~ii:n Nc~tni-~ of IVlothc:r ~~( Dec:c:ased , f~ Imq '~r~,, r-r. ;r Ivhdrue 1='I~acc ul l)~~,,th Soci31 Sec~uity Ncrmber of Dc:cezzsed I~ - ~ -- z-3u. Date of l3iltll of Deceased A 1:: at Death Nlonth ,Day Year N~iii'u~ c,l t I~, I~rl ,I ur ~~l,cai~l l~ ess ~ ..._~~.~~~ I lane, -iwn or City Cr,unty Pu,f:~oi~ Ir,r UVlueh F=tt~ccird is f-iequirer~ ~~, o~ ~,~~ ~~;~ UUtiat w~i~ your rc~hiUiirisliil) l0 11ic dece~ised? I~, vvtial czy,~ualy ari: you ~.iclincd"? -~-~----~ II ~iltoir,r~y, r,,:uni: ;i„,~ril:) of yoi-ir client fo ~eceased ::iytr~ ura of AI,I,Gc;iril _- Ad~lrc:a i,f Al,pli~'~inl _ -- ~' N Date (~--~ ~ - ----- __ -- ~,t)tUll~l F l L _f=C?R DMA`( I-1~ C~C'CUFdRIP+1G AS ~Di~ JANU~F~Y 1, 7~E38 ~IVi„ui,t~r of ~~cili,r._, rc:quest~d wiUi contlclenl7~al oausa of dealli - IVinnher c,l c:alnus requc~sleil wilhorrt confidiv~nlial cause of deul:h _,- 1_?K ~ A~k_ r?~t~lly-f Na~l~ pt~lf~ AG?RR~~~ W1-1~1~1~ I~~~oRt?'sHOU~.R B~ ~~N'I"' -_,-, -.,-m., I'~urrie _ Ac IcJre:_, s -- ---- --- Glty _ - --- ------- _ - ------------ --- State Lip Code _ L~y ht)l~l.~~~~l~r'1 ~fi/'~nl~l11 ,~-~~~MC~ItMOIf~ ~+Cy ~,.OCc"i-~ ~E:+~15~~"~I~' r,, w vc,l a ~r1 ~a I I:- t~t.a~~~{r-~-rN11_ N-r or- t I~AtA-r1-1 ~;+~~, ~O t~.~ ~~~ ..~,.~ ~~~0~,+~ vil ,I Ft;~~ ~~~,1 ~ ;~~ ~au>rl ~. {'~~1a~4.. Cf]IVIF'L;f"7E-FORM At~lD ktJ~I~C~S~ FCC :, f I f:: :f 14.00 pc:r co1)y ai Nu t=iecoril C~rhlicatian. Phase da nit send cosh or stamps. ........ ''r~t~r~,A~~ Fh~1tV1' oF~ `1 YF~~. _ _ _ _ ____._ ~. _._....____ _.T.__~__._____ _ _~ ..._.- _ IV,-,rne iii !)~c~~:~;se'~1 .Date of pr:rth or 1='eriod to Ue Covered by S~ rri~cl"r r li ~ t IVllllillct (_c`i"~ t _.___y__...-.__.,_.._.__._.__,._._.__.___._...__...______-_~.~T_.----------_._.~.-.---__-__-_. ~ _~~___ I I~d«tne ~~r f=~~il,er ;:~i C)c;c~~~~sed Sacial Security Ncunher at Deceased L~ul~ ~YYeYI , ~ 1(~ _ ~ -_ Z- ~ZZ _ 1=it~a _ rVligdle _ _ I-~asf _ Marcicn iJ~ant:~ c,t Nlutlrc.r of Dr.c.eased ~ -^~-{~ Date ai 13irtl, of Deceased A ] clt Death {-rest Niic:Jdl~ ~~ Nlontl~ Da Year Pl~ai:c G) l)~~;Uh N~.urre c,l FI1.,,p~l ~I_ar ~~I~~~c~t. Acss ~_.^~~~-yT r lage, ~-wn i~r~ City Gr~rurty Purl'ro~sa icrr VVluch t~ecxrrd is Required r VVl~r.al w<<s 4,, Irr vvl"r;rl i;ty,~ It ~Itoii,cy, ~ :iir~f~<ilur ~, ,; Acl~lr~,a u1 , ~~ ----- - _ _--- __._._:._(~i)tVlr~l F i L ~C?I~ t4t~A`1'1-IS_(JUCUi~.I~IIUC AS Oi= JANIJAF~Y "l '1+88 ~IVurnt„~r e,f cx~l~i~_~, rc,7uost~.d with conficl~~ntial cause of de~.rlh __ I~urr~l„~r 01 c:cyu~~s iequesfed withor_rt con'tid~~~~niial cause of dearth ,/~~ t