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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J,fiIP Lee Sa"M
COUNTY n. dclto-
ClTYrroWN V\Mppi~
~~~1~
~~~~A8
1. A. FUll. NAME
CURRENT SURNAME
Q.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE}..,..." Aft .. Aru:-
D. SOCtALSECURlTY NUMBER ~~~
2. RESIDENCEA. N~)Carolina B. ~bufg
C. CHECK ONE ~ CITY 0 TOWN 0 VILlAGE
AND
SPECIFY Chartnltp.
D. STREET ADDRESS 7~ 1;'1111 .IAM UlN!I, ~ R ZIP ~~
E. IS RESIDENCE WITHIN LlMlTS OF CITY OR INCORPORAlED VIl1AGFI I!! YES 0 NO
3. A. AGE 25 sa. DATE OF BIRTH M~ / 11 / ~
4. EMPLOYMENT
A. USUAL OCCUPATION Salesmen
B. TYPE OF INDUSTRY OR BUSINESS 84 IJlm~
5. PLACEOFBlRTH~~ne
6. FATHER
A. NAME Vemon ~ Saunde15 Jr
B. COUNTRY OF BIRTH I J S P. .
7. MOlliER
A. MAIDEN NAME Medb8 81en GlbaN'
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 0
....
S;
e(
Q
wi!
~u..
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DEAlli
o
I
STA"re ALE NUMBER
(THIS SPACE FOR STATE USE ONL l1
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FUll.NAME C.I F'rir.a-MAriP. ('~Dni
MlOIllE CURRENT SURNAME
-1
8. BIRTH NAME (MAIDEN HAMEl. IF DIFFERENT
c. ~~~~~A896
D. SOClAI. SECllRIfY NUMBER ~-
12. RESlIlENCEA.~roIi~ B. ~hll{g
C. CHECK ONE ~ CITY 0 TOWN 0 VILlAGE
~ Chartotte
D. STREET ADDRESS 7820 Ella Jane lane. Art R ZIP 28273
E. IS RESIDENCE WI1HIN UMJTS OF CITY OR JNCORPORAlED VILlAGE? 0 YES ~ NO
13. A. AGE 23 36. DAlE OF BIRTH ~ ..otAY ~
14. EMPLOYMENT
A. USUAL OCCUPATION SMa! WnrkRr
B. TYPE OF INDUSTRY OR BUSINESS A- Y N
15. PlACEOFBlR1H~~~~)
16. FATtiER
A. NAME Ricbgrrl ('..mnni
B. COUNTRY OF BlmwU S A
17. MOTtiER
A. MAIDEN NAME f(a1'Al"l MArte KI'AII&C
B. COUNTRY OF BlRTHlJ S A
18. NUMBER OF THIS MARRIAGE 1
19. ~alIR~~~US 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 B. HOW DID lAST MARRIAGE END? (3) 0 IllVORCE (3) 0 ANNULMENT (2) 0 DEAlH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTll DAY YEAR MONTll DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) AlIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNUlLED. PROVIDE lliE FOLLOWING INFORMATION
DATE OF DECREE PlACE ISSUED AGAINST WHOM DATE OF DECREE PlACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CI1YICOUNlY. STATEfCOUNl1lY.1F NOT USA) SaF SPOUSE (MONTH. DAY. YEAR) (CI1YICOU/lITY. STATEICOUNTRY. IF NOT USA) SaF SPOUSE
o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
'D 0 4TH 0 0
t of my knowledge and belief that the infonnation I provided is true and re that no legal impediment 8xists
OF BRIDE~
23. SUBSCRIBED AND
SIGNATURE OF TOWN
This license authorizes the maniage in New Vori< State of
Relations Law ~11 to perfoml mafriage ceremonies within New York
o If d1ecked. this license is to be used
24. TOWN OR CITY CLERK
USE CURRENT NAME
DATE 06101/2006
bride and groom named above by any person authorized by New Yori< Domestic
. THIS UCENSE VAUD IN NEW YORK STATE ONLY.
Iy for the purpose of a second or sUbsequent ceremony.
25. A. SOlEMNIZATION PERIOD BEGINS
DATE 0SID112OD6
NY 12590
STATE
27. TYPE OF CEREMONY
o tr"" REUGIOUS
9 DOTtiER. SPECIFY
TITLE
DME
MONTH
YEAR
MONTH
YEAR
ZIP
08:42AM 06
PM
02
2006 07
31 2006
1 0 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY bUTt.H6$S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF III TOWN OF 0 VILlAGE OF
SPECIFY \N ftP(J) N 6612
PA-STD~
~/ B/:J-O{)fc
. ,
/LbO
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) -'\Arit \I'\.\fl4 ( IX""" ~
SIGNATURE. 00.... iJ JlAJo.. -,.Jl~