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~~~
1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Ha~Marc RaHMilfNTSURNAME
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
COUNTYnlltr.he!=:!=:
CITYrrOWNW::!rringer
~~~~~C;1 ~nR .
~~~I~~~R14?
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lau~~bee Mulli~~ENT SURNAME
-1
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTKriwox
C. SVS~~~~~~~~EA~~c~~iatn8r .
D. SOCIAL SECURITY NUMBER 11 n-4R-??07
12. RESIDENCE A NY(STATE) BD~)ss
C. CHECK ONE 0 CITY oil TOWN 0 VILLAGE
AND I:l b" ,
SPECIFY,Ollg ~,eE:'p'>le
D. STREET ADDRE~ 101 r.herry Hill rlrivp. zlf~12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESool] NO
13. A. AGE51 3B. DATE OF BIRTH 11 do .!9J:;J:;
"MONTH llA Y YE.&:Fi
14. EMPLOYMENT
A. USUAL OCCUPATIONOffice Manager
B. TYPE OF INDUSTRY OR BUSINESS Merlir.::! I
15. PLACE OF BIRTHDo\ler [le1cw::!re
(CITY. STATE / COUNTRY IF NOT USA)
18. FATHER
,A. NAMEJo~eph Orin Kri'.^'ox
B. COUNTRY OF BIRTH J S A
17. MOTHER
A. MAIDEN NAME Mcro::!ret Ann Nir.ker!=:nn
B. COUNTRY OF BIRTH I S A
1B. NUMBER OF THIS MARRIAGE 2
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129-38-2475
2. RESIDENCEA.NXSTATE) B. q~ss
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND I:l ....1, .
SPECIFY ,Ollgl ""eepSle
D. STREET ADDREss41 01 r.herry Hill nrive ZIP 1 ?nO~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..t] NO
M~ /~~ /~i~Q
3. A. AGE5?
4. EMPLOYMENT
3B. DATE OF BiRTH
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Electrical
5. PLACE OF BIRTH~c';R~'rEf){tUNTRY IF NOT USA)
8. FATHER
A. NAME Samuel Ratner
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Pauline GrLlmet
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
. ..DIVORGE GIVll-ANNUbMENT--- ..-
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
n
DEATH
1
o
o
B. HOW DID LAST MARRIAGE END? (3)otJ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) t'J DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH02 / 019 / ~p4' c. DATE LAST MARRIAGE ENDED? MONT~n /~.J /-:. ?.Qfl?
D. ARE ANY FORMER SPOUSE(S) ALIVE? Iii!l'YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0?/10/?004 We!=:tr.he!=:ter r.nl mty. Ny ~ 0 1ST 06/1 ~/?OO? Pnllghkp.p.r~ip., NY ~ 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and say, that to the best of knowledge and belief that the information I provided is t e 0 legal impediment exists
as to my right to enter into the rnage e.
21. SIGNATURE OF GROOM~ "-
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y State of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New Yori< 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) .ln~.M1it~
SEAL SIGNATURE ~ r. ~ DATE 11 tn7/?007
MAILING ADDRESS
'-v-I ST~~ Mirlrllehll!=:h Rrl, WRrPcm~~~ F::!II~, s~n~ 12590ZlP
~~~R~~RT~~~ 'o~O~~N~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME, MO. DAY YEAR 00 RELIGIOUS l~CIVIL
DATE AND AT THE TIME AND .
PLACE INDICATED. II / 0 7 9 0 OTHER, SPECIFY
29. OFFICIANT i1
NAME (PRINT)
22. SIGNATURE OF BRIDE ~
TIME
YEAR
MONTH
YEAR
MONTH
AM
06:40 PM 11 08 2007 01 06 2008
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CouNTYflu j1 if-g;<;'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .31. TOWN OF 0 VILLAGE OF
SPECIFY I8U@'ff!<.EEf)S:;1S
SIGNATURE~
DOH-9B (0312008)
