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Application to Local Registrar for Copy of Death Record Donna Lent Town Clerk TC-02 Supplement A Patricia Ryan Chief Deputy Town Clerk One Independence Hill Farmingville NY 11738 631 451-9101 FAX 451-9264 Notarized Authorization to Mail a Death Certificate to a Post Office Box or Third-Party Address I hereby authorize the Office of the Town Clerk of the Town of Brookhaven to mail the requested death certificate to Signed Phone Number Date STATE OF COUNTY OF On the day of in the year before me...
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