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COUNTYQlltr.hpSS
CITYfTOWNW;:!ppinop.r
~~~:~~ ~hR -
~~~:~~~ 11
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ga~Dberarlelil YOM~TSURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
PaU;!g~f Ann HebtRRENT SURNAME
~
1. ,A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~JtAr::r~~~t~~~~~~pllng
D. SOCIAL SECURITY NUMBER 1 ?9-56-3606
12. RESIDENCE .-NY (lnlltr.hp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY...o TOWN 0 VILLAGE
AND _D hk .
SPECIFycOllg p.p.r!=;le
D. STREETADDRES621 Sheafe Rd: #57
z,P12601
o YElYb NO
~66
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?7 -!'\?-4?Qn
2. RESIDENCE A.NY;STATE) B. DIe'JsrJ;wss
C. CHECK ONE 0 clT'l\;O TOWN 0 VILLAGE
AND P hk .
SPECIFY 0110 PP. p!=:I P.
D STREET ADDREss6?1 Sheafe Rd; #57 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEso'tJ NO
3. A. AGE39 38. DATE OF BIRTH Mg~ / 'i~ /\~A~8
4. EMPLOYMENT
A. USUAL OCCUPATION Corrections
B. TYPE OF INDUSTRY OR BUSINESSnr. Sheriff!=; Dept
5. PLACE OF BIRTH=::n1lahkp.F!D!':ip. NY
(CITY. 'STATE I COlJNTRY I~ NOT USA)
6. FATHER
A. NAME Aller 10SE'ph YO'InCl
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME Anna Margaret Angell
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER QF-PREV1QUSMARRIAGES.WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGIt\.1 3B. DATE OF BIRTH nR M
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATlmM/;:!rehnll!=;e Worker
B. TYPE OF INDUSTRY OR BUSINESsGap. Inc.
15. PLACE OF BIRnCold Sorina. NY
(CITY, STATE I COlll7i'RY IF NOT USA)
16, FATHER
A. NAMeRll!=:!=;p.1I Arthllr H;:!rt
'B. COUNTRY OF BIRTtIJ S A
17. MOTHER
A. MAIDEN NAMEJean Marie Matheson
B. COUNTRY OF BIRTtIJ 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
8. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that t
as to my right to enter into the marnage
21. SIGNATURE OF GROOM ~
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provide
o 0
o 0
o 0
o 0
t no legal impediment exists
~
by New York Domestic
MONTH
YEAR
AM 09
6:25 PM
06
2007
11
04 2007
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~iC.JIsItR
C. LOCATION OF CEREMONY
(CHECK ONE AN~CIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY W~<;.tZ"
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
SIGNATURE~
nf'\U . 00 In') nnnc.\