Sullivan, J Craig V.S. 64 (5/70) STATE OF NEW YORK
DEPARTMENT OF HEALTH
BUREAU OF VITAL RECORDS
APPLICATION FOR CORRECTION OF CERTIFICATE OF DEATH
RE: DECEASED - fF i G 1'3/A^fe-A,0 Rd DISTRICT NUMBER -
DATE OF DEATH - /../-9-7e/ REGISTER NUMBER -
n PLACE OF DEATH -Pee."e:,�. rc,-L-, STATE NUMBER -
I, -�) • l�Q Al.9' _ci 11,'✓„.a<-,i of so/I' U f4n) d- i N It-4 l4-i✓, .:Zn. ! - . ,
desire to (Add Information) (Cause a Correction of Information) to the certificate of death
identified above, as follows:
ITEM IN ERROR AS IT APPEARS AS IT SHOULD BE
(Or Omitted)
'%4.e a y !! ,c-G-y� .0 • al „eatil Ili'!;,t Ze kg.e_zt tid ..e 6.4.4,_ 2a - 1 � m / q /
' , C
Documentary evidence submitted herewith--in--support-of this applicationincludes:
EXPLAIN REASON FOR ERROR OR OMISSION: g4 �. ,Jz.,,�-,7 ,tom-- .--. u-�.- �---- i
eife.r.c.O_i c.i� C/(4 .ti—, 4:4'vyy>,.t r' `-71- ( :;,44—.1-9,--c e ((�3^t . I-e1- —,0' it
To be completed by applicant:
Under the penalties of perjury, I hereby affirm that the statements made herein are
true and correct to the best of my knowledge.
ASIGNATURE OF APPLICANT RELATIONSHIP TO DECEASED DATE
iZ ' -I-- ,e,42,„.4-_, 4--/7/7J ,___
To be co IT
leted by registrar of vital statistics:
The above information has been added to the local record of death on file in this
office.
SIGNATURE OF REGISTRAR DISTRICT NUMBER DATE