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One day after the incorporation of the Board of Managers, Harlem Valley State Hospital
came into being. It opened on April 24th, 1924 "for the care and treatment of the insane" as part of an act to discontinue the farm and industrial prison at Wingdale. Buildings A, B and C had already been constructed at the State Road (Route 22) site and money was soon requested to buy adjoining farmland and buildings to build a root cellar, dairy barn, piggery and poultry house for 3000 chickens. With 24 patients admitted on August 11 from New York City and Long Island, the hospital was ready to become part of the history of Harlem Valley.
Between 1925 and 1929, the certified capacity of the new hospital rose from 250 to 1294. During that time, the Board of Managers, which, in later years, became the Board of Visitors, approved changing the course of the State Route 22 so that it would skirt most of the grounds instead of running directly through.