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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Andr8WD~{istoph8r ~",WEb~AME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY [)lltchess
CITYfTOWN \^'appino~r
~~~:~c: 1 3RR .
~5~I~J~R 91
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cr~bR1 Lynn BOJ3~ENT SURNAME
11. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 A.-RR-A.~A.~
12. RESIDENCE A. N~STATE) B. D~bs~ss
C. CHECK ONE D CITY Iitl TOWN D VILLAGE
~~CIFY W~rrino~r
D STREET ADDRESS 34 Apt A Chelsea Ridge Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE 27 3B. DATE OF BIRTH 11 ,./.j Q /'j' QRR1
--mmTH 15'AY VEJti
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 610-10-0537
2. RESIDENCE A. NV B. n, It,..h~SS
(STATE) "ll551Ji:!'1'Vl
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND '^' .
SPECIFY appmger
D. STREET ADDRESS ~A. Art A Ch~I~p.~ RirlOp. Or ZIP 1 ?~~n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES i!l NO
Mo~l / DQy1 / yli7S
3. A. AGE 31
4. EMPLOYMENT
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Interinr n~~iCJn~r
B. TYPE OF I~DUSTRY OR BUSINESS Rp.tail Sales
15. PLACE OF BIRTH ~~ratnn~ ~nrinns NY
. (CITY, STAT~ COUNTRY IF tlBT LISA)
16. FATHER
A. NAME p~.,~al Bond
'B. COUNTRY OF BIRTH Er::lnr.p.
17, MOTHER
A. MAIDEN NAME Rn)(~nnp. I Fmigh .
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF.PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
A. USUAL OCCUPATION Control Room Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Fn~roY Prnrllldion
5. PLACE OF BIRTH Edmond \fI.,IA
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Andnil'}lf Speedy Zastrow
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A. MAIDEN NAME All'>yandr<;i CI~ir ~~nn
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
o
o
MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) D ANNULMENT (2) D DEATH
/ (
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
1ST D D 1ST
2ND D D 2ND
3RD D D 3RD
4TH D D 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I de
as to my right to enter into the marnage state, . ~ /~I
21. SIGNATURE OF GROO'~ --=- 22. SIGNATURE OF BRIDE~ .
~ USECU NT NAME '
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
D If checked, this license is to be used oniy for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
D
D
D
/
DATE
by New York Domestic
~
{ SEAL }
~
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
AM
02:00PM
2009
10
19 2009
08
21
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1,( CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY WJq~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY~: f ~~WN OF A' VILLAGE OF
SPECIF~'~rA-J/~
29. OFFICIANT
NAME (PRINT)
SIGNATURE~