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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 JerelJilML~ohn '^'aQ~~:clr SURNAME
I
-I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
couNTDlltchess
CITYrrowt1Nappinger
~~~~~~1j 368 .
~G~I;~~~ ? 1
L 0 SUPPLEMENTAL FILE
,FROM THE BRIDE
MAli!::!::::! JA::!n r,llisinner
MIDDLE Ci;tIIRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 131-7?-?fl33
2. RESIDENCE AN Y B. Qllooni
(STATE) (CClllrrrY)
C. CHECK ONE "",0 CITY 0 TOWN 0 VILLAGE
AND At'
SPECIFY ~ n n a
D. STREET ADDRES.c:?349 31 st Rtreet ZIP 111 05
E. IS RESIDENCE WITHIN UMITS OF CIlY OR INCORPORATED VILLAGE? ....0 YES 0 NO
3. A. AGI2Q 3B. DATE OF BiRTH .;Q~ / ;'~Y /j~8
4. EMPLOYMENT
A. USUAL OCCUPATION Self Fmployed
B. TYPE OF INDUSTRY OR BUSINESS Technical Theater
5. PLACEOFBIRTfHllnson New York
(CITY. STATE'I COUNTRY IF NOT USA)
6. FATHER
A. NAMESte'^'art \N~hler'3
B. COUNTRY OF BIRTHI J R A
7. MOTHER
A. MAIDEN NAME Holly I awsnn
B. COUNTRY OF BIRTH I J R A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE __ ____._.ClVIL.ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGM~~~le~~
(OPTIONAL - SEE REVER~
D. SOCIAL SECURITY NUMBER - -0873
12. RESIDENCE.N Y ~lleAns
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~clI:Astnria
D. STREET ADDREs2349 31 st Street ZI~ 1105
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? .....0 YES 0 NO
n 1476
DAY YEAR
13. A. AG61
3B. DATE OF BIRTH
07
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATlorMarketing
B. TYPE OF INDUSTRY OR BUSINES~rchestria
15. PLACE OF BIRTlDes Moines. Iowa
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEMichael .Jnsesph Guisinger
'B. COUNTRY OF BIRTlJ S A
17. MOTHER
A. MAIDEN NAMeMargaret Jean Johnson
B. COUNTRY OF BIRTlJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DlVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATf1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,-.- YEAR
(3) 0 ANNULMENT
/ /
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSCY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
0 0 1ST 0 0
0 0 2ND 0 0
0 0 3RD 0 0
0 0
t no legal impediment exists
23. SUBSCRIBED ANO SWORN TO/AFFIRMED BEF
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of th authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York S e. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used on y for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo
YEAR MONTH
SEAL SIGNATURE~ TE09/17/2007
'-v-I M~OMfdaTs i erS"Falls NY 12590
STREET CITYITOWN STATE
~~~R~~RTr~J 'o~O~~N:,zEE~ 26, SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMEO ABOVE ON THE TIME O. DAY YEAR 0 ~ RELIGIOUS
DATE ANO AT THE TIME AND 1_ AL I!J
PLACE INDICATED. ~.~ -. 1() Z04? 9 0 OTHER, SPECIFY
~~t~n~~~;p& ~L E. E>.l..lIet TITLE_R,v'~(NO
SIGNATURE~ ' DATE q. ~O-07
~Uz.lv'iU ~ ~. "30 N..",,1o&1l: N~ 100 36
STREET CITYfTOWN STATE ZIP
3D WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
==~;~ :::,;: Jt2l1t:J~O
DOH-sa (0312006)
ZIP
YEAR
11
16 2007
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY D\lY.IIE~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY \JAP"1>V:J6 ~
,