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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ricbj[@ DEI"id S~~T SURNAME
COUNTY r1 I Jtr.hF!~~
CITYffOWNWappingF!r
~~~:~~T1 ~nR
~5~1:~~RR 7
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER n71-7?-R417
2 RESIDENCE A. NXSTATE) B. q~~~~ss
C. CHECK ONE ...0 CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Rp~cnn
D. STREET ADDREssn C:olonial Road; Apt #68 ZIP 12508
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? otJ YES 0 NO
3. A. AGE28 3B. DATE OF BIRTH Melt / lH / 1~l8
4. EMPLOYMENT
A. USUAL OCCUPATION Sur\leyor
B. TYPE OF INDUSTRY OR BUSINESS C:nn~trllr.tinn
5. PLACE OF BIRTHRrnm( !,.J'{
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Alan Lawrence Stein
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME M~rr.i~ Snnj~ RII Im~tF!in
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~RMtFR~U'&T&SMARRIAGES-WHICHENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
n
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 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) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
N~Hle CatherMJ~ESiefermcgRRjM~~A~PF!
~
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTSietermann
C. sy~~~:tfN~~~~~~~~~~~tei n
D. SOCIAL SECURITY NUMBER u98-58-4 77 5
12. RESIDENCE ANY Bnlltr.hF!~~
(STATE) (COUNTY)
C. CHECK ONE o,l] CITY 0 TOWN 0 VILLAGE
AND
SPECIFYRF!acon
D. STREET ADDRESS Colonial Road: Apt #68
ZIP 12508
...n YES 0 NO
~7n
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
13. A. AGE31 3B. DATE OF BIRTH 01 AR
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONSr.rpF!n PrintF!r
B. TYPE OF INDUSTRY OR BUSINESsApparel
15. PLACE OF BIRTHPOlluhkr-:apsie, NY
(CITY. mATE / COONTRY IF NOT USA)
16. FATHER
A. NAME.I~mF!~ \I~lpntinF! SiF!fF!rm~nn
B COUNTRY OF BIRTtU S A
17. MOTHER
A. MAIDEN NAME Theresa June Brewster
B. COUNTRY OF BIRTr!. 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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
"- YEAR
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say, that to
as to my right to enter into the mamag
21. SIGNATURE OF GROOM~ '
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is true an
o 0
o 0
o D
o 0
Impediment exists
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 bride and groom named above by any person authorized
Relations Law !ill to perform marriage ceremonies within New York 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
~
{ SEAL }
'-v-I
NAME (PRINT)
22. SIGNATURE OF BRIDE~
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
20 Middle
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 08/08/2007
er Falls NY 12590
OWN STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
ZIP
AM
05:53 PM 08
09
2007
10
07 2007
28. PLACE WHERE MARRIAGE OCCURRED
1 'CIVIL
A. STATE NEW YORK B. COUNTY -hrt:h;(S1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 11- TOWN OF 0 VILLAGE OF
v ~U'1~ tr.tffd:-
E
f'""~",, ~}('
SPECIFY
31.
SIGNATURE~