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1 . A. FULL NAME
~ I A II: UJ- NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST BenihelJD~pnshehni CM~~QfflnAME
CURRENT SURNAME
'=' I "" I C. ru...c l'4lUmCl;;n
(TH/S SPACE FOR STATE USE ONL Y)
COUNTY[)lltchess
CITYrrOWN \N::lrrinoF!r
~~~:~C;nR8 .
~~~I:~~R 1 fi fi
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Aimee Nozil
MIDDLE
~
11. A. FULL NAME
FIRST
~
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 138-7 4-1R7 4
2, RESIDENCE A, N'XSTATE) B. ~rss
C. CHECK ONE 0 CITY.,lJ TOWN 0 VILLAGE
AND '^' .
SPECIFY apprngE'r
0, STREET ADDRESS 11C: Surrey I ane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A. AGE28 3B. DATE OF BIRTH MO~~ / dA~ / ~E~19
4. EMPLOYMENT
A. USUAL OCCUPATION Project A rchi\/ist
B. TYPE OF INDUSTRY OR BUSINESS ~nVF!rnmF!nt
5. PLACE OF BIRTH ~~~~Ty,:rrC~UN~rIF NOT USA)
6. FATHER
A. NAME Beniheh B Morgan
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Cf1eryl nF!ni!::F! Smith
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
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE f\II n rO::l n
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129-72-3334
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRES~3C Surrey Lane
ZIP 12590
o YES~ NO
;(981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE27 3B. DATE OF BIRTH 07 A56
MONTH DAY
14. EMPLOYMENT
A. USUALOCCUPATloNRegistered Nurse
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH New Rochelle Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEFrit7 Nozil
'B. COUNTRY OF BIRn.Haiti
17. MOTHER
A. MAIDEN NAME Jacqueline Miller
B. COUNTRY OF BIRTt-IJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o
o
DEATH
n
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
a:'
W
m
:;
:>
Z
Q
Z
..
li:i
W
~
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the Information I provided is true a d that I d
as to my right to enter into the~arnage state.
21. SIGNATURE OF GROOM ~ ' . JI'IJ I' ,~ 22 SIGNATURE OF BRIDE .
." US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
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.
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
} NAME (PRINT) '~'P-c.. ~
{SEAL SIGNATURE. Cl..l- -~~ DATE 10103/?008
MAILING ADDRES 11:47 AM
'-v-' sTRfR MiddlenlJ~h Rei. Wap~~~~Js Falls's~Tr 1259~p PM 10
~~~R~~~R;~~~ 10~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 n"RELlGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. I t 3c.J PM I U ,z( ::t c)cJ 0 OTHER, SPECIFY
29. OFFICIANT '"":"\ n I ';: L (3 (: j) I-
NAME (PRINT) -4J 'C.(..(.,..., c:.--' J ~ r u I 0_
SIGNATURE. 3 4/ S fh LJ.I l/>""'''.3- A. {! ~ DATE' '0 /2(/"- J d,,,+---
MAILING ADDRESS ( . JJ I (I- I IlJ Y 1.'/7'./ j
3"t' ~ fY\ ~,Q ~"-JI4 J A j'(J{. /./...... ...); ....f /..>... ~ ....,..,- 0 ~ "'tt
STREET' CITYrrOWN STATE ZIP
30. WITNESS TO CERE ONYjJ 31. WITNESS TO C REMONY
NAME (PRINT) cJ)7'11 .... NAME (PRINT) W Y\ ~.
12
02 2008
o 0
o 0
o 0
o 0
t no legal impediment exists
10/03/2008
DATE
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
04
2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY AJQ..vJ V,v t
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
crClTY OF 0 TOWN OF 0 VILLAGE OF
NQ. '-" Va-It.
SPECIFY
SIGNATURE.
DOH-98 (03/2006)
SIGNATURE.