121
+
t'-
N
co
NO'
C")f-
<(
f-
U)
....J
LL
o
-0
f- C
Z CO
O' -
UJ ~
ilIO
"
5t'-~u..
~O:5u..
UJN:!<(
~ .....~
i= ..- ;::
<( 0
a: .t::
t;; ~
ffi<C
a:
W
(!)
<(
cr
a:
<(
:;
u.
o
W
I--
<(
U
u:
i=
a:
W
U
W
a:
W
:J:
;:
UJ
UJ
W
a:
"
"
<(
>-
u.
C3
W
Q.
UJ
w
en
z
w
0
~
+
~:t:z W
j:!!::Q
w;:~ ~
a:~_ <
I--wz
UJ..J::i! 0
::lUW
::i!(!}5 ii:
f-ZU) ~
~5u.
C3~0 a:
[OU) w
01-->- 0
W~(3
....z",
O~
z::;!;
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ja:jljQ~EStc'JOn ~OONT SURNAME
COUNTY Dutchess
CITYn-OWN \^'appinger
DISTRICT . .
~~~I~~~R1368
NUMBER 121
1. A. fULL NAME
fiRST
Q.
N
B. BIRTH NAME. If DIffERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 059 66 0218
2 RESIDENCE A. FL,STATE) B. Qr~ooc
C. ~~6CK ONE .jJ CITY 0 TOWN 0 VILLAGE
SPECIfY Orlando
o STREET ADDRESS 6457 Niilrcooiiee Road ZIP 32827
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ollI YES 0 NO
MOW / ~~ / ~1
3. A. AGE 26
4. EMPLOYMENT
38. DATE OF BIRTH
A USUAL OCCUPATION Pilot
B. TYPE OF INDUSTRY OR BUSINESS ,Ajrline
5 PLACE OF BIRTH Q~~~ ~ );'c9ll
I . A Cd If AI
6. FATHER
~
:>
<(
Q
A NAME Harvey Kolin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan Bonnie Cohen
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
\f' .. b ,'I..hitt
. Ir9Ma/a ee I IU"""COFl~NT SURNAME
~
11. A. FULL NAME
fiRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE I.( 0 I i n
(OPTIONAL' SEE REVER~}
D. SOCIAL SECURITY NUMBER 012-66-1124
12. RESIDENCE A FL (STATE) B.O~~
C. CHECK ONEJl] CITY 0 TOWN 0 VILLAGE
AND
SPECIFY 0 rl and 0
D. STREE1 ADDRESoB.dt:i7 N::lrr.nn~~p.p. Rn::lrl zIP~?R?7
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ol'J YES 0 NO
13. A AGE25 3B. DATE OF BIRTH ~TH /()1AY -1~~~
14. EMPLOYMENT
A USUAL OCCUPATION Ph ii1rmiilciit
B. TYPE OF INDUSTRY OR BUSINESS Pharrl'8cp.lltir.::l1
15. PLACE OF BIRTH\^'orCE'stl'>r Ma
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Lee Piilul Tibbitti Jr
B. COUNTRY OF BIRTHl J S A
17. MOTHER
A. MAIDEN NAME lacqllE'line ThE'rE's~ Ke'1nerly
B. COUNTRY OF BIRTHl I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
22. SIGNATURE OF BRIDE~
o
o
o
a:
w
'"
::i!
::l
Z
o
Z
<(
f-
W
W
a:
t;
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 and that I
as to my right to enter into the marr ge state.
U
23. SUBSCRIBED AND SWORN TOI RMED BEFORE M
SIGNATURE OF TOWN OR CITY ERK ~ DATE
This license authorizes the marriage in New authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonie 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
21. SIGNATURE OF GROOM~
~
{ SEAL}
'-..t-/
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
09:56AM
PM
2008
10
28 2008
08
30
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SATE
27. TYPE OF CEREMONY
o ~LIGIOUS
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
/tRC PM
29 OFFICIANT ~L I. .J I 4'" I .A
NAME (PRINT) ~~f[1k "k.~r',
SIGNATURE~ ~
MAILING ADDRESS v ) I
II'Jf13 ~k114t" C,~ (... ""(4I(de, #4. :$t131.
STREET CITYrTOWN
3D. WITNESS TO CEREMONY
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
y~t~
TITLE --1'L~;
DATE $1 k$lAS~ Z~&cj,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY~thlJf
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
STATE
31.
NAME (PRINT)
SIGNATURE~