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NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)
. ..... . UUICnCSS
g,'rr~g.WNWappingor
NUMBER~ 368
REGISTE
NUMBER 130
-- .....Wv Ivnt\.
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICA TE OF
MARRIAGE
FROM THE GROOM
Neil .&:iman StuaEtR~Jfl' SURNAME
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AlliSQ~olpann8 La9i~T SURNAME
-.J
1. A. FULL NAME
FIRST
11. A. FULL NAME
Q.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 136 70 7818
2. RESIDENCE A. ."" B. n. '.-"'-;-33
PI ~STATE) '-1SW1fff,...
C. CHECK ONE 0 CITY,JJ TOWN 0 VILLAGE
AND
SPECIFY ra'vvliflg
D. STREET ADDRESS 24 Cushing Green SOblth ZIP 12564
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.,l] NO
3. A. AGE 34 3B. DATE OF BIRTH McQ~ / Q.O / 1JJJ 4-
4. EMPLOYMENT
A. USUAL OCCUPATION rolief: Officer
B. TYPE OF INDUSTRY OR BUSINESS L::JW Enforcement
5. PLACE OF BIRTH ~~ /~tyNONJA)
6. FATHER
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~tuart
(OPTIONAL - SEE REVERS!l
D. SOCIAL SECURITY NUMBER 103-62-5687
12. RESIDENCE ANY BDlltl""hQSS
(STATE) lretlfif'l'!
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND n "
SPECIFY r a'AI rng
D. STREETADDRESs?4 r."~hino r,rAFm !=\nllth ZIP 1 ::>5fl4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YESolJ NO
13. A. AGE2-9 3B. DATE OF BIRTH ~TH /-f ~AY ,{~l~
14. EMPLOYMENT
A. USUAL OCCUPATION L.a\J/y~r
B. TYPE OF INDUSTRY OR BUSINESS Prn~pr.lltnr
15. PLACE OF BIRTH Yo~IJ,l~J I L~lMrRY IF NOT USA)
16. FATHER
.A. NAME Anthony Labat~
B. COUNTRY OF BIRTHI J ~ A
17. MOTHER
A. MAIDEN NAME Elaine G P::lpnntn~
B. COUNTRY OF BIRTAU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME -Neil Aikman Stuart
B. COUNTRY OF BIRTH U 8 /\
7. MOTHER
A MAIDEN NAME Janoann Kathryn Prout
B. COUNTRY OF BIRTH U 8 II,
B. NUMBER OF THIS MARRIAGE -4
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
~
~
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
Q
o
DEATH
n
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH : 0 0 4TH 0 0
I duly swe!lr/affirm, dep,ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no '~egal j ediment exists
as to my nght to enter IntO the marrr state. , d I J A . ^ . ?/fl
21. SIGNATURE OF GROOM ~ d. . 22. SIGNATURE OF BRIDE ~ () M.A/dfI YI /1
REN USE CU~ NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
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 by New York Domestic
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
DATE O~/151/00E~
,.-'-.,
{ SEAL }
'-v-1
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
02: 18PM 09
14 2008
16
2008
11
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1)'1.1 iU,~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY VJ /f {,v ~J"'II/ c-
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
t'lA.....