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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST ..Jami~LJo"Qph RY~eN~YuRNAME
COUNTY n'ltr.hp.~~
CITYfTOWN W~rrinop.r
~~~:~c: 1 ~nA '
~~~I~~R A9
1 . A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 105-66-nOA.?
2. RESIDENCE A. N (~ATE) B. ~\AI
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY I~cksomfill~
D. STREET ADDRESS 1 O?~ Fllri~ nrivA ZIP ?R540
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? DYES i'l NO
MO~ /J2~ /~
3B. DATE OF BiRTH
3. A. AGE 25
4. EMPLOYMENT
A. USUAL OCCUPATION Marine Corpi
B. TYPE OF INDUSTRY OR BUSINESS ~Ailit~ry
5. PLACE OF BIRTH B~acon l\Ie\llJ york
(CITY, STATE I !::OUNTRY IF NOT USA)
6. FATHER
A. NAME James JOieph Riley, Jr
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME le~np.ttp. I
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARF,lIAGE 1
~tp.VAn~
9. PREVIOUS MARRIAGES
A. NUMBER. OF PREVIOUS.MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) D DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME FIRST D~liiI:,~[1 a M Ri I~~RENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT P8datlilla
c. s~S~~M~~~~WC~~s~iley
D. SOCIALSECURITYNUMBER 07A.-74-7571
12. RESIDENCE A. N r B. ()n~lnw
1!l"TATE) ~
C. CHECK ONE D CITY ijj!l TOWN D VILLAGE
~~~CIFY .I~r.k~nnvi IIA
D. STREET ADDRESS 1 023 Furia Drive ZIP 28540
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t'J NO
~TH ~~AY -1~~~
13. A. AGE 23
14. EMPLOYMENT
A. USUAL OCCUPATION Rer.p.rtinni~t
B. TYPE OF INDUSTRY OR BUSINESS MnclArn ExtArminating
15. PLACE OF BIRTH Rrnnx NAW Ynrk
(CITY, STAtE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Rocco I=rank Pp.rl::ltp.lI~
. B. COUNTRY OF BIRTH I J S A
3B. DATE OF BIRTH
17. MOTHER
A. MAIDEN NAME N~nr.y Mir.hAIA D' Amici
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
o
(3) D ANNULMENT (2) D DEATH
/ /
."- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
..
20. 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
D 0 1ST
D D 2ND
D D 3RD
D 0 4TH
best of my knowledge and belief that the information I provided is true
~
{ } NAME (PRINT)
SEAL SIGNATURE.
MAILING ADDRESS
'-v-' .
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED. 9
22 IGNATURE OF BRIDE~
TIME
MONTH
YEAR
YEAR
MONTH
DATE 08/09/2007
r F lis NY 12590
WN STATE ZIP
27. TY~OF CEREMONY
o ~ELIGIOUS 1 D CIVIL
9 D OTHER, SPECIFY
TITLE
SIGNATURE.
DOH-98 10312006\
AM
01 :21 PM 08
09
2007
10
07 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT1f. D~s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~GE OF
SPECIFY WAfP/~6 bru..s