COURT COUNTY OFIN THE PROBATE COURT OF MAHONING COUNTY, OHIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.JUDGE TIMOTHY P. MALONEY CORRECTION OF BIRTH RECORDAPPLICATION, FINDING AND ORDER FOR CORRECTION OF BIRTH RECORDCalendar No.[R.C. ยง3705.15; Loc. R. 75.6 (A)]CASE NO. JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s), the Applicant, prays that his/her birth record be corrected in accordance with section 3705.15 of the Ohio Revised Code, as follows:Applicant's Full Name (at time of birth) [Social Security No. ] Place of Birth Date of Birth (City, State, Hospital, Home Address)Applicant's sex at the time of his/her birth:Q Male Q Female. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOFather's Full Name Age of Father (at time of birth) Birthplace of Father Mother's Maiden Name Age of Mother (at time of birth) Birthplace of Mother Item(s) to be corrected or added.Item reads as should read Item reads as should read(Supplement, if necessary, and attach).GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableWherefore the undersigned applicant, being first duly sworn, says that the facts stated in the foregoing Application are true as he/she verily believes.,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomApplicant's SignatureFull AddressCity, State, ZipArea Code/PhoneYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Sworntobeforemeandsignedinmypresencebytheapplicantaforesaidthisdayof,20.(SEAL)Notary Public, one of the Justices of theCourt in Witness, Honorableday of, 20 County,JUDGMENT ENTRY(Attorney must sign above and type name below)The Court, upon consideration of the aforesaid and the evidence submitted, finds that the applicant personally appeared and was examined, that notice of hearing was completed or was dispensed with and Orders that the birth record of applicant be corrected in accordance with the facts hereinabove set forth; and that a certified copy of the Order of the Court be forthwith transmitted to the Director of Health, at Columbus, Ohio, as provided by law.Hon. Timothy P. Maloney, JudgeAttorney(s) forIherebycertifytheaboveisatruecopyoftheapplicationandentryintheforegoingmatter.Hon. Timothy P. Maloney, JudgeOffice and P.O. Address(SEAL)By Deputy ClerkTelephone No.: Facsimile No.: E-Mail Address:Form 75.6 (A) M.C.Revised 09-11-02Mobile Tel. No.:The State of , County of :Affidavit of PhysicianAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.I, , do hereby certify that I was the physician in attendance at the birth of(Typed or Printed Name)Calendar No., the applicant herein, and that the facts in the application are true, as I verily believe.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Signature of Attending PhysicianAddressSworntobeforemeandsignedinmypresencethisdayof,20.(SEAL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Notary PublicTHE PEOPLE OF THE STATE OF NEW YORK TONOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the following affidavits of two persons, relative or non-relative, having personal knowledge of the facts or by clear and convincing documentary evidence or such other evidence as the Court deems sufficient.TheState of , County of :Affidavit ofI, (Age Years), do hereby certify that I have personal knowledge of the facts statedGREETINGS:(Typed or Printed Name)in the within application by virtue of and that the facts stated herein are true, as I verily believe. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Signature of AffiantAddresslocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomSworntobeforemeandsignedinmypresencethisdayof,20.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.(SEAL)Notary Public, one of the Justices of theThe State of , County of :Affidavit ofCourt in Witness, Honorableday of, 20 County,I, (Age Years), do hereby certify that I have personal knowledge of the facts stated(Typed or Printed Name)(Attorney must sign above and type name below)in the within application by virtue of and that the facts stated herein are true, as I verily believe. Signature of AffiantAddressAttorney(s) forSworntobeforemeandsignedinmypresencethisdayof,20.(SEAL)Office and P.O. Address Notary PublicTelephone No.: Facsimile No.: E-Mail Address:Form 75.6 (A) M.C.Revised 09-11-02Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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