133
ll.
N
+
w
....
M;'"
0'"
CO
N
..--
en
en
w
a:
o
o
<
it
u
W
0-
en
+
~~z
~?i2 W
a:"'~ ~
tii~~ 0
::lOW
~ Cl 5 i::L
!z:!;(f) -
~~l5 ~
lEoen W
~~~ 0
l!:!~",
o~
Z::i~
COUNTY nlltr.hl'!!=:!=:
CITYfTOWN W~rrinop.r
~~~~~; 136R '
~~~I:J~R 1 ~~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
TO~LPsrrsll G~~NTSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
KareM7Ddf'nnifer S~~\QNT SURNAME
~
1 , A, FULL NAME
1 L A, FULL NAME
FIRST
FIRST
l-
S;
<C
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
0, SOCIALSECURITYNUMBER 07&\-7?-&\&\6R
2 RESIDENCE A, N ~TATE) B, q!tl~~5iS
C, CHECK ONE 0 CITY .,l[I TOWN 0 VILLAGE
AND P hI<' .
SPECIFY nllO l'!er~lp.
D. STREET ADDRESS 1 S~Ip.m r.Ollrt ZIP 12603
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES I(] NO
3, A- AGE 34 3B, DATE OF BiRTH M~ / ~A~ / l~13
4, EMPLOYMENT
A, USUAL OCCUPATION Management
B, TYPE OF INDUSTRY OR BUSINESS ~~r Inr.
5, PLACE OF BIRTH Anr.hor~np. ~ AI~!=:k~
(CITY, STATE I COUNTRY IF NOT USA)
6, FATHER
A, NAME Richard I ~lMrence Gate9
B- COUNTRY OF BIRTH I J S A
7. MOTHER
A- MAIDEN NAME ,Io~nnp. (';~il n~vis
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
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~N?r"~~~t~~~~~s~ate5i
D. SOCIAL SECURITY NUMBER 07?-7?-3417
12. RESIDENCEANY(STATE) B.~'>5
C, CHECK ONE 0 CITY 0 TOWN ojZJ VILLAGE
~~~CIFYW~rringp.rs F~lIs
0, STREETADDRESs12 Roy Avenue z,P12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? ..0 YES 0 NO
13. A. AGE26 3B. DATE OF BIRTH 10 ,,08 ;(QR1
MONTH DAY YEAR
14, EMPLOYMENT
A- USUAL OCCUPATION M~n~gp.mp.nt
B, TYPE OF INDUSTRY OR BUSINESS Banana Republic
15. PLACE OF BIRTHRrnnxL New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME j3r1Ir.1'! R Smith
B. COUNTRY OF BIRnU S A
17. MOTHER
A. MAIDEN NAME Elizabeth Carboni
B. COUNTRY OF BIRT~ S A
lB. 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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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
1ST
2ND
3RD
4TH
I duly swear/affirm. dep.ose and say, that to the be
as to my right to enter into the marnage state.
,-~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
dg and belief that the information I provided is true and tha
o
o
o
a:'
w
III
::!
:>
z
c
z
<
Iii
w
a:
Ii;
21, SIGNATURE OF GROOM~
USE UR N NAM
23, SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the
Relations Law ~11 to perform marriage ceremonies within New York Stat THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a sBCond or subsequent ceremony.
{ ~ } ~:;~~:I: CIJ CLERC 25. A. SOLEMNIZATION PERIOD BEGINS
TIME MONTH YEAR
SEAL SIGNATURE ~
'-v-I MA~18GrOO~ 09:10 AM 10 10 2007
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PEA-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND AM I
PLACE INDICATED, : 30 PM (CJ 7
~,;~~:m 1'?5 G/(, ~,S l' 73<.!.LJ?w
SIGNATURE~ 1JloJ[!., ~ f ~
MAILING ADDRE~ P. W ~
STREET CITYfTOW
30. WITNESS TO
DATE 10/09/2007
by New York Domestic
W
en
z
W
o
::l
MONTH
YEAR
12
08 2007
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~:rc..ffe-S
10 CIVIL
TITLE
ft. c. ff/~
/0/13/07
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY W AfP(~ MLL.S
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~
/2.00
31. WITNESS TO .C