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COUNTY [)I Itr.hF'!!':.!':.
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
los~RPaniel GiMmBRSURNAME
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Yi
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
PAri IIAnA RArm::!n
MIDDLE CURRENT SURNAME
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1. . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 083-70-0688
12. RESIDENCE ANY B.nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESs43 Trenton Road
ZIP 12524
o YES..o NO
;(q8?
YEAR
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D SOCIAL SECURITY NUMBER 1 07 -R4-R~?7
2. RESIDENCE A. P~!;TATE) B. q~~are \
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY llprAr r.hir.hA!':.tAr
D. STREET ADDRESS ~1~1 MAetinghouse Road, ZIP 19061
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES otJ NO
3 A AGE 27 3B. DATE OF BIRTH MO'l-Q / Q} / ~R80
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS AArn~pace
5. PLACE OF BIRTH ~I~:S%~E; bo~JRY IF NOT USA)
6. FATHER
A NAME Michael Gillma'1
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Amy .1::mA Honig
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE?
/1'8
DAY
13. A. AGE 25
3B. DATE OF BIRTH
11
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Musir. Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Bronx, Ny
(CITY. STATE I COUNTRY IF NOT USA)
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16. FATHER
A. NAMERir.hard Rerman
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Pamela Marilyn Roth
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / ~
MONTH DAY YEAR
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
o 0
o 0
o 0
and that I declare that no Ie al impediment exists
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
est of m,( k~011~e and belief that the information I provided is
21. SIGNATURE OF GROOM~ ) ~ 22. SIGNATURE OF BRIDE
~SE C RENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRME FOR ' l .PII ~ ~'L;^
SIGNATURE OF TOWN OR CITY CLERK" _.LA L ~.:..:r...,/.
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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
DATE
07/11/2008
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
DAY
YEAR
MONTH
DAY
YEAR
TIME
08:48AM 07
PM
12
2008
09
09 2008
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY b~~
C.
29. OFFICIANT
NAME (PRINT)
SIGNATURE"
SIGNATURE"