HomeMy WebLinkAbout471724-001Aurora R. Valenti
TOMPKINS COUNTY CLERK
320 North Tioga Street
Ithaca, NY 14850
607-274-5431
Fax: 607-274-5445
No. of Pages: 1
Receipt No. 471724
DATE: 04/21 /2005
Time: 02:15 PM
Document Type: MISC RECORDS
INSTRUMENT NUMBER
*471724-001 *
Delivered By: MAZZA & MAZZA
Return To:
Parties To Transaction: CHARLES W HURLBUT
Deed Information
Consideration:
Transfer Tax:
RETT No:
State of New York
Mortuage Information
Mortgage Amount
Basic Mtge. Tax:
Special Mtge. Tax:
Additional Mtge. Tax:
Tompkins County Clerk Mortgage Serial No.:
This sheet constitutes the Clerk endorsement required by Section 316-A(5) & Section 319 of the Real
Property Law of the State of New York. DO NOT DETACH
Tompkins County Clerk
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NEW YORK STATE
DEPARTMENT OF HEALTH
CLG�STFRNUMBFR RESIDENCE CERTIFICATE OF DEATH
IAIt: I-ILE NUMBER
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CANCER
1 NAME HRST MIDDLE J LAST
2 SEX
3A DATE OF DEATH 13B HOUR
I
MALE FEMALE
MONTH DAY YEAR
Charles W. Hurlbut
[at ❑z 1
Febi 17 12005 ' 8:26 m
4A PLACE OF DEATH HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER 46 IF FACILITY, DATE ADMITTED
(Check one) DOA ER OUTPATIENT INPATIENT HOME RESrIDDEENCE FACILITY (specify) MONTH DAY YEAR
El El 0 0
4C NAME OF FACILITY (If not tacdiygive address) 4D LOCALITY (Check one and specify) 4E COUNTY OF DEATH
j CITY VILLAGE TOWN j
175 Williams Glen Road IkR ❑ ❑ of Ithaca Tompkins
4F MEDICAL RECORD NO 4G WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION? (It yes, specify institution name, ciy orTown, counyand state)
NO YES
--_— ® ❑
5 DATE OF BIRTH
6A AGE IN 68 IF UNDER 1 YEAR 6C IF UNDER 1 DAY 7A CITY AND STATE OF BIRTH (Itnot USA, Country and 7B IF AGE UNDER 1 YEAR, NAME OF HOSPITAL OF
' I ' I
YEARS ENTER ENTER Reg/on/Provmce) BIRTH
MONTH DAY YEAR
months days ' hours minutes
I
80 ys' New York New York
Nov.
25 1
1924
8 SERVED IN US ARMED
9 DECEDENT OF HISPANIC ORIGIN? Check the boxes that best describe whether the decedent is Spanrie0ispanrcdahno 10
DECEDENTSRACE Check one ormore races to indicate what die decedent consideredbmtsedorhersed to be
FORCES? (Specryyears)
NO YES
ipallo, not SpanishMispanic/Labno B ❑Yes, Mexican, Mexican Amencan, Chicano A
® Whde/Caucastan 8 ❑ Black or African American C ❑ Asian Indian D ❑ Chinese
❑ 0 91
C ❑ Yes, Puerto Rican D ❑ Yes, Cuban E
❑ Filipino F ❑ Japanese G ❑ Korean H ❑ Vietnamese
4 3-45
E ❑ Yes, Other Spamsh/Hispanic/Labno (Specify) J
❑ Native Hawaiian K ❑ Guamanian or Charmino Ni ❑ Samoan
❑ American Indian or Alaska Native (specify)
11 DECEDENT'S EDUCATION Check the box thatbestdescnbes the highestdegree ortevel of school completedat the note ofdeath
N
1 ❑ s 8th grade 2 ❑ 9th-12th grade, no diploma 3 ❑ High school graduate or GFD
4 ❑ Some college credit, but no degree 5 PP Associate's degree 6 ❑ Bachelor's degree P
❑ Other As -an (sperm, R ❑ Other Pacific Islander (specify)
7 ❑ Master's degree 8 ❑ Doctorate/Professional degree S
❑ Other (specay)
12 SOCIAL SECURITY NUMBER 13 MARITAL STATUS 14 SURVIVING SPOUSE Enternamed
NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED marred or separated ffsun^hang spouse is
104-ies-8o8i 01 :Uz. ❑3 04 05 ivife,etuermxcsr.name Phyllis E. Angus
i
15A USUAL OCCUPATION (Do not enter retired) ISB KIND OF BUSINESS OR INDUSTRY 15C NAME AND LOCALITY OF COMPANY OR FIRM
I Co nell University,
Graphic Designer Education !Ithaca, New York
16A RESIDENCE
16B County or Region/Province
16C LOCALITY (Check one and specify) 16F IF CITY OR VILLAGE, IS RESIDENCE
(State or Country
if not USA
CITY VILLAGE TOWN i WITHIN CITY OR VILLAGE LIMITS?
dnotuSA) New York
Tompkins
® ❑ ❑ Ithaca C?:OYES ONO IF NO, SPECIFY TOWN
f
16D STREET AND NUMBER OF RESIDENCE 16E ZIP CODE
175 Williams Glen Road 14850
17 E OF FIRST MI LAST
18 MAIDEN NAME FIRST MI LAST
HER
OF MOTHER
2L Charles W. Hurlbut
Adelaide Sweze
19A NAME OF INFORMANT 19B MAILING ADDRESS (include zip code)
I
Mrs. Phyllis Hurlbut ' 175 Williams Glen Road Ithaca.
20A t j7BURIAL 2 O CREMATION 3 OMEEM AL 4 0HONTH OLD 5 O DONATION 20B- PLACE OF BURIAL, CREMATION, REMOVAL OR OTHER DISPOSITION. t 20C LOCATION, (City or town and state)
SaENTOMBMENT 02 1 26 2005Frear Memorial Park ' Ithaca, New York
21A NAME AND ADDRESS OF FUNERAL HOME 1 21 B REGISTRATION NUMBER
I
Ness -Sibley Funeral Home, 23 South St.,4TruiWnsburg, NY 14886 ' 01325
22A NAME OF FUNERAL DIRECTOR 122E SIGN ATU FUNERAL I CTOR.
22C REGISTRATION NUMBER
Joseph L. Sible I
03670
23A SIGNATURE OF REGIS 23B DATE FILED 24A BURIAL OR REMOV MIT UED BY 24B DATE ISSUED
' t t
MONTH A YEAR MONTH DAY YEAR
V
ITEMS 25 THRU 33 COMPLETED BY CERTI G PHYSICIAN -- OR -- CORONER/ RO R'S PHYSICIAN OR MEDICAL EXAMINER
25A CERTIFICATION To the best of my knowledge, death occurred at the time, date and place and due to the causes stated
�t
Ce [dhotis Name" [�
r%k` /I License No I Signature t /f Monts Da Year
Palk
Ja k �— mead cpfL4 l f� � � (i
Certifiers Title Attending Physician 0 LiPhysician acting on behalf of Attending Physician n rj i
caviiAot
f[Ttoromer 2 ❑ Medical Examiner/ Deputy Medical Examiner
25B, If coroner is not a physician, enter Coroner's Physician's name & title
License No
sign re Month Day Year
25C If certifier is not attending physician, enter Attending Physician's name & title
License No
Address
26A Attending physician Montle D Year Month Year
26B Deceased last seen alive Month D Year
26C Pro niouneed Month Day Year Time
attended deceased FROM 70 °1
by attending physician p
� I M E oN AT M
d�
w Coroner
27 MANNER OF DEATH UNDETERMINED PENDING
28 WAS CASE REFERRED TO
29A AUTOPSY? 298 IF YES, WERE FINDINGS USED TO DETERMINE
NATURAL C SE ACCIDENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION
CORONER R MEDICAL EXAMINER'
,N.O/ YES REFUSED i CAUSE OF DEATH?
❑2 ❑3 ❑4 ❑5 ❑6
0 NO 1 [--]YES
D ❑1 02 ' 0❑NO 1 El YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL
30 DEATH WAS CAUSED BY (ENTER ONLY ONE CAUSE PER LINE FOR (A), (B), AND (C) ) B AAPPROX@tMATEE INTERVAL
SET AND
NE DEETWEEN ATH
PART I IMMEDIATE CAUSE
DUE TO OR AS A CONSEQUENCE OF
(e)
DUE TO OR AS A CONSEQUENCE OF / J
PART II OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO
DID TOBACCO US NTRIBUTE TO DEATH?
DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A)
0 ❑ NO 1 YES 2 ❑ PROBABLY 3 ❑ UNKNOWN
31A. IF INJURY, DATE i HOUR t 31 B INJURY LOCALITY (City or town and county and state) 131C DESCRIBE HOW INJURY OCCURRED 31D PLACE OF INJURY i 31E. INJURY AT WORK?
MONTH DAY YEAR t I NO YES
I m' I I I ❑0 ❑1
31 F IF TRANSPORTATION INJURY, SPECIFY
132 WAS DECEDENT
33A IF FEMALE
33B DATE OF DELIVERY
1 ❑ Dmer/Operaior 2 ❑ Passenger 3 ❑ Pedestrian
HOSPITALIZED IN NO YES
0 ❑Not pregnant wdhm Nsl year 1 ❑ Pregnant at time of death 2 ❑ Not pregnam, but pregnant whin 42 days of death
MONTH DAY YEAR
4 ❑ OTHER (spe )
LAST 2 MONTHS?
0 ❑ 1
3 ❑ Not pregnant, but pregnant 43 days to 1 year before death 4 0 Unknown 9 program wrthm past year