On November 03, 2022 a
Party Statement
was filed
involving a dispute between
Deanna Marie Tucker,
and
Mary T. Bassett M.D., M.P.H.
The Commissioner, New York State Department Of Health,
for Special Proceedings - CPLR Article 78
in the District Court of Albany County.
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FILED: ALBANY COUNTY CLERK 11/03/2022 12:55 PM INDEX NO. 908334-22
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 11/03/2022
EXHIBIT B
Birth Certificate of Petitioner’s Mother
FILED: ALBANY COUNTY CLERK 11/03/2022 12:55 PM INDEX NO. 908334-22
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 11/03/2022
NewYoAState Departinent
. . ofHealth
OFFICE OF VITAL STATISTICS
one°;¡;;;e ï ,i;;ies,
CERTIFICATE OF BIR T H
1. PLACE OF BIRTH: Registered No..............
...
STATE OF NEW YORK .......
2. USUAL RESIDENCE OF MOTHER (Whero does mother the?)
.. . .. h f £,
hd b. TOWN a. STATE
g,.g) g µ b. COUNTY
e. TOWN
GR: -=. c. CITY OR VILLAGE
d. CITY OR VILLAGE
Is residencewitNn its
limits?
-
8 W ' '
E a '""""""
O ttAMMS 8mfATH "O"ESS
È E 5'
si. 1uKes ownnN
3. CHILD'S \
NAME fit..der) Û ve-.
gg Q 4. $E sa. THISBIR H sh. IF TWIN OR TRIPLET (This child
born) 6. DATE
Lg SINGLE WIN (Month) (Day)
O TRIPIET IST Q END O 3RD (Year)
g yn
33
lal FATHER OF CHILD
7. FULL NAME
& COLOROR RACE
(Attime of this birth)
10. BIRTHPLACE (Statey foÃr Ign countrF) O
O U A O 19b. IND
a .' YEARS OF BUSINESSOR NDUSTRY
T D
E 12, FULL MAIDEN NAME
.
13. COLOROR RACE
14. AGE (Attime of this birth)
15. SIRTHPLACE ( er forebp: copntry)
M 18. CHILREN REVIOUSLY BORNTO THIS MOTHER
YEARS (Do NOT include this
chRd)
R OTHER chil-b. Now
17. LENGTH OF PREGNANCY18. many
T OF CI D AT BIRTH living? wereWm OTHER children
W are now deadr
c. Bow manr thAdren were st8l-
h W h M m
WEEKS GM8. OR ,2958.
as 19a. WAS THE BLOODOF THIS
D'S MOTHER TESTED FOR 19b. DATE TEST MADE
SYPHILIS 19c. IF
NO TEST STATE REASON
O THEREFOR:
During pregnancy?YES NO At delivery? TES
O NO "
19
20a. tHAT PREVENTIVE FOR OPHTHALMIA NEONATORUMDID
YOU USE? tob. IF TE THE REASONTHEREFOR:
NONE,
04 21. MOTHER'S MAILING ADDRESSFOR
REG TION NOTICE:
I hereby certify thatI 22a. SIGNATURE OF ATTENDANT
s O 22b. ADDRESS
Ste. DATE SIGNED
us ta.DATE FILED BY LOCAL 24. REGISTRA *S GNATUR
25. GIVEN NAME ADDED
Document Filed Date
November 03, 2022
Case Filing Date
November 03, 2022
Category
Special Proceedings - CPLR Article 78
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FILED: ALBANY COUNTY CLERK 11/03/2022 12:55 PM INDEX NO. 908334-22 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 11/03/2022 EXHIBIT B Birth Certificate of Petitioner’s Mother FILED: ALBANY COUNTY CLERK 11/03/2022 12:55 PM INDEX NO. 908334-22 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 11/03/2022 NewYoAState Departinent . . ofHealth OFFICE OF VITAL STATISTICS one°;¡;;;e ï ,i;;ies, CERTIFICATE OF BIR T H 1. PLACE OF BIRTH: Registered No.............. ... STATE OF NEW YORK ....... 2. USUAL RESIDENCE OF MOTHER (Whero does mother the?) .. . .. h f £, hd b. TOWN a. STATE g,.g) g µ b. COUNTY e. TOWN GR: -=. c. CITY OR VILLAGE d. CITY OR VILLAGE Is residencewitNn its limits? - 8 W ' ' E a '"""""" O ttAMMS 8mfATH "O"ESS È E 5' si. 1uKes ownnN 3. CHILD'S \ NAME fit..der) Û ve-. gg Q 4. $E sa. THISBIR H sh. IF TWIN OR TRIPLET (This child born) 6. DATE Lg SINGLE WIN (Month) (Day) O TRIPIET IST Q END O 3RD (Year) g yn 33 lal FATHER OF CHILD 7. FULL NAME & COLOROR RACE (Attime of this birth) 10. BIRTHPLACE (Statey foÃr Ign countrF) O O U A O 19b. IND a .' YEARS OF BUSINESSOR NDUSTRY T D E 12, FULL MAIDEN NAME . 13. COLOROR RACE 14. AGE (Attime of this birth) 15. SIRTHPLACE ( er forebp: copntry) M 18. CHILREN REVIOUSLY BORNTO THIS MOTHER YEARS (Do NOT include this chRd) R OTHER chil-b. Now 17. LENGTH OF PREGNANCY18. many T OF CI D AT BIRTH living? wereWm OTHER children W are now deadr c. Bow manr thAdren were st8l- h W h M m WEEKS GM8. OR ,2958. as 19a. WAS THE BLOODOF THIS D'S MOTHER TESTED FOR 19b. DATE TEST MADE SYPHILIS 19c. IF NO TEST STATE REASON O THEREFOR: During pregnancy?YES NO At delivery? TES O NO " 19 20a. tHAT PREVENTIVE FOR OPHTHALMIA NEONATORUMDID YOU USE? tob. IF TE THE REASONTHEREFOR: NONE, 04 21. MOTHER'S MAILING ADDRESSFOR REG TION NOTICE: I hereby certify thatI 22a. SIGNATURE OF ATTENDANT s O 22b. ADDRESS Ste. DATE SIGNED us ta.DATE FILED BY LOCAL 24. REGISTRA *S GNATUR 25. GIVEN NAME ADDED