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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ilfw"'l M.~SURNAME
o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
of my knowledge and belief that the information I provided is true and that I dec:e~ legal impediment exists
" ,^n>EO'mwE~ ~~::~
the bride and groom named above by any person authorized by New York Domestic
State. THIS UCENSE VALID IN NEW YORK STATE ONLY.
only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY ~c.
ClTYITOWN \N8ppil"\g8l'
~:=c;:;r 1~
~~:J~A 74
1. A. FUU NAME
RAST
Q.
I:;j
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRtAGE
(OPTIONAL - SEE REVERSE) ~ I!>JI ......ft&'
D. SOCIAL SECIlRITYNUMBER ~~
2. RESIDENCEA.~VOJk B. ~ell
C. CHECK ONE 0 CITY O.,rowN 0 VILlAGE
AND Ws"
SPECIFY PPngIW
D. smEET ADDRESS 811....~ ~
E. IS RESIDENCE WI1liIN lA!ITS OF CI1Y OR INCORPORATED V1llAGE'1
3. A. AGE 25 38. DATE OF BIRTH
ZIP 12590
o YES O.
4. EMPLOYMENT
A. USUAL OCCUPATION fJev&tor eontrartor
B. TYPE OF INDUSTRY OR BUSINESS Kone
5. PLACEOFBIRTH ~~W
6. FATHER
A. NAME Robed Max8net"
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME ~ [)wWao
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DMlRCE (3) 0 ANNULMENT (2) 0 DEAlli
C. DATE LAST MARRIAGE ENDED? / /
MON1li 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) (ClTYICOUNTY. STA1CICOUNTRY. IF NOT USA) SELF SPOUSE
III
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{ SEAL}
'-v-I
I
STA're ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
l'~ Anne S~
MI D C SURNAME
11. A. FUUNAME
RAST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. ~~~~SE) Max.~
O. SOCIAL SECURITY NUMBER OR?-84-3248
12. RESJDENCEA. _VoW B.~
C. CHECK ONE 0 CITY 0 ~0'IiN 0 VILlAGE
AND ....1-"
SPECIFY ~A''''
D. smEET ADDRESS 811 C~ CI!fI ZIP 12590
E. IS RESIDENCE WI1liIN UMfTS OF CITY OR INCORPORATED VIllAGE? 0 YES D.
13. A. AGE 26 3B.DATEOFBIRTH~
14. EMPLOYMENT
A. USUAL OCCUPATION ~.pdinnJJI ThAnlphd
B. lYPE OF INDUSTRY OR BUSINESS I-WM ~M ~
15. PLACE OF BIRTH ~Lt!fMAtVftIY
(CITY, STATE I t:OUNTfIy IF NOT USA)
16. FATHER
A. NAME .~ ~
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME NtV'AAn VAQgJ'ln
B. COUNTRY OF BIRTH USA
lB. 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 (3) 0 ANNULMENT (2) 0 DEAlH
C. DATE lAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULlED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (ClTYJCOUNTY. STATEICOUNTAY, IF NOT USA) SELF SPOUSE
TIME
MONTH
YEAR
ZIP
AM
03:06A
06
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE? CEREMONY
R 0 l1YffEuGIOUS
9 0 OTHER, SPECIFY
1 0 CIVIL
28. PlACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY OR.(."..AA~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY N.euJ v.9l~J~()r
29. OFFICIANT
NAME (PRINT)
1/
NAME (pRINT)
SlGNAruRE~
( ./
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