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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
OMfles ~ct.,. CURRENT SURNAME
1ST 0 0 1ST 09J21fJ004 caRRel. N.....' YOIt 0 iI
2ND 0 0 2ND 0 0
3RO 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm. depose and say, tI1al to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m nag state. , f'l - ..../~
21.SIGNATUREOFGROOM~~' REOFPRIDE~ ~fih1l..t L!_J~
USE CURRE N Q USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME . nr:::_..~
SIGNATURE OF TOWN OR CITY Cu:AK~ DATE ~
This license authorizes the marriage in New Vork State of the ride and groom named above by any person authorized by New Vork Domestic
Relations Law ~11 to perform marriage ceremonies wlthin New York Sta THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CL.ERK 25. A. SOL.EMNIZATlON PERIOD PEGINS
{ '} NAME(PRINT) Joh~~
SEAL SIGNATURE~, ~
MAILING ADDRESS
'-v-I. .
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
COUNTY Dutch_
CITYITOWN 'NappiAgel'
DISTRICT .
~~~I~~R1.8
NUMBER 58
1. A. FULL NAME
..
I'l
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AfTER MARRIAGE
(OPTIONAL. BEE REVERSE) .
D. SOCIAL SECURITY NUMBER 132 62 i774
2. RESIDENCEA. N.,lfork B. ~
C. ZlgCK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY Hy8e PeFk
D. STREET ADDRESS 282 PiRebr88k DFI\.. ZIP 12538
E. IS RESIDENCE wmllN UMITS OF CITY OR INCORPORATED VIu.AGE? 0 YES.jji!I NO
3. A. AGE 43 3B. DATE OF BIRTH ~ / 2S / ytQ62
4. EMPLOYMENT
A. USUAL OCCUPATION HespitaI FiAfilAee
B. TYPE OF INDUSTRY OR BUSINESS IleeIth QUest
5. PLACE OF BIRTH ~-t__eut
6. FATHER
~
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A. NAME I"amek Jereme Gessid)'
B. COUNTRY OF PIRTH USA
7. MOTHER
A. MAIOEN NAME Cl8Ire Jaelesen
B. COUNTRY OF PIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENOED BY
DIVORCE CIVIL ANNULMENT
DeATH
o 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEA'\ll
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) (CITYICOUNTY, STATEICOUNTAY.IF NOT USA) SELF SPOUSE
a:
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULl NAME JetAMsFie NelftlflYle
.J
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT L:.ynch
C. Slf~~~~~C~~spasid)'
D. SOCIAL SECURITY NUMBER Q72 6& 2312
12, RESIDENCE A. NertfA~<<k B. ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY CaRRel
D. STREET ADDRESS5Q5 VIsta OR The Lake ZIP 10512
E. IS RESIDENCE WmllN UMITS OF CITY OR INCORPORATED VIu.AGE? 0 YES i'l NO
13.A. AGE 37 3B.DATEOFBIRTH L ~AY _
14. EMPLOYMENT
A. USUAL OCCUPATION AsGcHIRtaRt
P. TYPE OF INDUSTRY OR BUSINESS Health - Quest
15. PLACE OF BIRTH ~~NT~.
16. FATHER
A. NAME JeseptI LynBh
P. COUNTRY OF BIRTHlrelsRct
17. MOTHER
A. MAIDEN NAME Mal)' Fa.
B. COUNTRY OF BIRTHlrelaAct
18. NUMBER OF THIS MARRIAGE 2
19. ~~ij~~~lR~rPh'l:<tlf8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
4 9 9
P. HOW DID LAST MARRIAGE END? (3) Iil'oIVDRCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? M~ / a1 /2QQ4
D. ARE ANY FORMER SPOUSE(S) ALIVE? Jijt\'ES 0 NO
20. 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
TIME
MONTH
YEAR
MONTH
YEAR
DATE 05Q.<t.Q0Q6
ZIP
AM
PM 05
23 2006
25
2008 07
ATE
27. TYPE OF CEREMONY
o 9"RELIGIOUS
9 0 OTHER. SPECIFY
1 0 CIVIL
28. PLACE WHERE MARRIAGE OCCURRE~
A. STATE NEW YORK B. COUNTYfI/ t(-tA.J.t?J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF e(TOWN OF 0 VILLAGE OF
r?4-'lZ-l?/ei-
SPECIFY