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COUNTY nlltr.hp.!,:!,:
CITYfTOWN W~rrinop.r
~~~:~c: 1 ~RR .
~5~1;~~R 90
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M~R~h ~a.rgil~~RRENT SURNAME
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~!tarp. r.(;Im::lJCURRENT SURNAME
.J
1. A. FULL NAME
11. A FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SYS~*~Mtt:~~rt~~~~~s~ a rg iI aj
D. SOCIAL SECURITY NUMBER 1 04- 7 4-5631
12. RESIDENCE A. NY B. nlltr.hp.!,:!,:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY \2l TOWN 0 VILLAGE
~~~CIFY Fi~hkill
D STREET ADDREss208 Jefferson Blvd
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 3R'i-Q? -R?7?
2. RESIDENCE A. N);'TATE) B. ~~ess
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
~~~CIFY Fisl,kill
D. STREET ADDRESS ?OR .Ip.ffp.r~nn Rlvrl ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 26 3B. DATE OF BiRTH MO~~ / ~ / y~83
4. EMPLOYMENT
A. USUAL OCCUPATION Entreprenellr
B. TYPE OF INDUSTRY OR BUSINESS.. Rp.~t~llr~nt
5. PLACE OF BIRTH np.trnit 1\111
(CITY, STATE'/ COUNTRY IF NOT USA)
16. FATHER
A. NAME Mir~~h r.~m::lj
'B. COUNTRY'OF BIRTHMontene~ro
17. MOTHER
A. MAIDEN NAME Justa Micakovic
B. COUNTRY OF BIRTHMontene~ro
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
ZIP 12524
o YES~ NO
AqRR
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 22 3B. DATE OF BIRTH nq /??
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Ar.r.n1 mtino
B. TYPE OF INDUSTRY OR BUSINESS Mbia
15. PLACE OF BIRTH Manhattan NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Deda Margilaj
B. COUNTRY OF BIRTH Mnntp.np.grn
7. MOTHER
A. MAIDEN NAME Tp.rp.7::1 np.rlvllk::lj
B. COUNTRY OF BIRTH Mnntp.np.grn
8. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH.
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. . - YEAR
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
age and belief that the information I provided is true
o 0
o 0
o 0
o 0
impediment exists
21. SIGNATURE OF GROOM.
w
en
z
W
(,)
:I
USE CURRE
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 ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A SOLEMNIZATION PERIOD BEGINS
/ 0/2009
by New York Domestic
~
{ } NAME (PRIN
SEAL SIGNATURE
MAILING
'-..-' .
MONTH
YEAR
YEAR
TIME
MONTH
DATE 08/20/2009
Falls NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o ~RELlGIOUS
9 0 OTHER, SPECIFY
1 0:57AM
PM
2009
10
19 2009
08
21
28. PLACE WHERE MARRIAGE OCCURRE? ~
A. STATE NEW YORK B COUNTY IJJh'k~f~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY_Wi-1h r.;Lt1- L~/
10 CIVIL
29. OFFICIANT
NAME (PRINT)
TITLE
VC?vO +-O'r
DATE
H-vv, +1 cLcd e/ IJ 1
STATE
v
..s- e-l co-
cc..
SIGNATURE'-