At a term of the Surrogate's Court
of the State of New York, held in
and for the County of BRONX at
851 Grand Concourse on_____
Present: Hon. Lee L. Holzman.
SURROGATE
...................................
In the Matter of the Adoption of ) File No. 15AD2004
A Child Whose First Name Is )
JANE ) ORDER OF ADOPTION
) (PrivatePlacement)
___________________________________
The Petition of JOHN DOE and JANEY DOE, verified the ______ day of APRIL, 2004, having been duly presented to this Court, together with an agreement on the part of the petitioning adoptive parents to adopt and treat as their own lawful child and whose birth day is JUNE 25, 2004, and who was born at BRONX, NEW YORK as set forth in the petition for adoption herein, said petition having been attached thereto and made a part thereof a document setting forth all available information comprising the adoptive child's medical history; together with the affidavit(s) of
JOHN DOE, JANEY DOE,THE BIOLOGICAL MOTHER and JOE DOE, THE BIOLOGICAL FATHER
____________________ and the consents of
JANEY DOE,THE BIOLOGICAL MOTHER and JOE DOE, THE BIOLOGICAL FATHER
______________________________________________________________________________;
AND, although his consent is not required, the Court having given notice of the proposed adoption to JOE DOE
[recite facts relative thereto ]
wherein he, as the biological father, on December 14, 1999 executed, before a notary, an Extrajudicial Consent to this adoption proceeding as well as to date he has not responded in any way to this Court's Notice of Proposed Adoption, dated March 20, 2000, and served by certified mail, return receipt requested on April 1, 2000;
AND the aforesaid petitioning adoptive parents and the adoptive child and all other persons whose consents are required as aforesaid having personally appeared before this Court for examination, except JOE DOE, THE BIOLOGICAL FATHER ;
AND an investigation having been ordered and made and the written report of such investigation having been filed with the Court, as required by the Domestic Relations Law;
(AND the Court having (shortened) (dispensed with) the six month waiting period between its receiving the petition to adopt and this order of adoption, pursuant to section 116 of the Domestic Relations Law, because ________________________________________________________________________________________
AND the adoptive child having resided with the petitioning adoptive parent(s) since JANUARY 1, 2004 (and the judge having dispensed with the six month period of residency with the adoptive parent(s), pursuant to section 116 of the Domestic Relations Law because _____________________________________________________________________________________
AND the court having inquired of the statewide central register of child abuse and maltreatment and having been informed that the (child) (adoptive parent(s)) (are) (not) a subject of or another person named in an indicated report filed with such register as such terms are defined in section 412 of the Social Services Law, (AND there being available to this Court findings of a court inquiry made within the preceding twelve months, of the statewide central register of child abuse and maltreatment that the (child) (adoptive parent(s)) (are) (not) a subject of or another person named in an indicated report filed with such register as such terms are defined in section 412 of the SocialServices Law) and the Court having given due consideration to any information contained therein;
AND this Court being satisfied that the best interests of the adoptive child will be promoted by the adoption and that there is no reasonable objection to the proposed change of the name of the adoptive child;
NOW, on motion of SUSAN CHANA LASK, Attorney for the petitioner(s) herein, and upon all the papers and proceedings herein, it is
ORDERED that the petition of JOHN DOE and JANEY DOE for the adoption of JANE, a person born on JUNE 25, 1993, at BRONX , NEW YORK, be and the same hereby is allowed and approved; and it is further
ORDERED that the said adoptive child shall henceforth be regarded and treated in all respects as the lawful child of the said adoptive parent(s); and it is further
ORDERED that the name of the said adoptive child be and the same hereby is changed to JANE DOE and that the said adoptive child shall hereafter be known by that name; and it is further
(ORDERED that the Clerk prepare, certify and deliver to petitioners a certifictate of Adoption; and it is further
ORDERED that the child's medical history, heritage of the parents, which shall include nationality, ethnic background and race; education, which shall be the number of years of school completed by the parents at the time of the birth of the adoptive child; general physical appearance of the parents at the time of the birth of the adoptive child, including height, weight, color of hair, eyes, skin; occupation of the parents at the time of birth of the adoptive child; health and medical history of the parents at the time of birth of the adoptive child, including all available information setting forth conditions or diseases believed to be hereditary, any drugs or medication taken during pregnancy by the mother; and other information which may be a factor influencing the child's present or future wellbeing, talents, hobbies and special interests of the parents as contained in the petition shall be furnished to the adoptive parents; and it is
ORDERED that this order, together with all other papers pertaining to the adoption, shall be filed and kept as provided in the Domestic Relations Law and shall not be subject to access or inspections except as provided in said Law.
Dated: ______, 2004.
ENTER
___________________________________________ SURROGATE
Agreement of Adoption and Consent Private Placement, Based on Official Form [FormDRL 111, 115(4)]
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
-----------------------------------------
In the Matter of the Adoption of ) (Docket) (File) No. _______
A Child whose First Name is ) AGREEMENT OF ADOPTION
JANE DOE ) (PrivatePlacement)
_______________________________
The under signed petitioning adoptive parent(s) hereby agree(s) to adopt the above named adoptive child and to treat said child in all respects as (his)(her)(their) own lawful child and to extend and assure to said child all the rights, benefits and privileges incident to such relationship, and to incur and fulfill all the responsibilities of (a) parent(s) with respect to said child.
Dated: APRIL __, 2004.
__________________________________/______________________________Adoptive Parent: JOHN DOE/ signature
__________________________________/______________________________
Adoptive Parent: typed or printed name / signature
STATE OF NEW YORK )
) ss.:
COUNTY OF NEW YORK )
On this _______ day of APRIL,1990, JOHN DOE, the person who executed the foregoing instrument, personally came before me and acknowledged that he executed the same.
________________________
Notary Public
STATE OF NEW YORK )
) ss.:
COUNTY OF _______ )
On this _______ day of _______,_______, the person who executed the foregoing instrument, personally came before me and acknowledged that (he)(she)executed the same.
_______________________
Notary Public
STATE OF NEW YORK )
) ss.:
COUNTY OF _______ )
On this _______ day of _______, _______, proven to me by the oath of _______, an attorney admitted to practice in the State of New York, to be the person(s) who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
____________________________
Judge of the _______ Court
s 22:110 Supplemental Affidavit, Private Placement Adoption, Based on Official Form [Form]
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
In the Matter of the Adoption of ) SUPPLEMENTAL
A child whose First Name is ) AFFIDAVIT
) (PrivatePlacement)
JANE DOE )
) (Docket) (File) No. ______
_________________________________)
STATE OF NEW YORK ) ss:
COUNTY OF NEW YORK )
JOHN DOE (and _________________)
being duly sworn, depose(s) and say(s):
1. Deponent(s) (is) (are) the same person(s) who on APRIL__, 1999 filed in this Court a petition for adoption of the abovenamed adoptive child.
2. Deponent(s) (is) (are) over the age of twenty-one years, citizen(s) of the United States, and (unmarried) (married and living together) (married and living apart).
3. The post-office addresses, place(s) of residence and home telephone number(s) of petitioner(s) (is) (are)
1500 METROPOLITAN AVENUE, #10, BRONX, NY 10462; (718) 829-1900
4. Home phone number: (718) 829-1900
5. Petitioner(s) hereby state(s) that there has been no change of circumstances whatsoever since the filing of said original petition, dated APRIL, 2004, except as follows: NONE
_________________
JOHN DOE
_______________________________________ _________
Adoptive Parent: typed or printed name signature
_______________________________________ _________
Adoptive Parent: typed or printed name signature
Sworn to before me this ______ day of APRIL, 2004.
____________________________________
Judge of the ______ Court