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Get NY DOH-1928 2003-2024

Ate 1. Name: First Middle Mother 2. Sex: Male 3. Date of Birth: Month Day 4a. County (NYS) of Birth: Year First 5a. Maiden Name: 5b. Social Security Number: First 6a. Name: Father Last 6b. Social Security Number: 4b. Town of Birth: 4c. City or Village of Birth: Middle Last 5c. Was mother's consent to the adoption required at the time of adoption or was mother's signature required on an instrument of surrender? Yes No If NO, were parental rights terminated? Middle 6c. Was .

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