042
o
m
J,!)
N
T'""
~
z
.m
~
II
i
I
00
(;'
l.@
t
-Ii
a
Q
&.
I
~
o
o
<(
>
"-
o
W
0-
00
ZIZ
~~~
W <(
tr"'N
tr-
f-WZ
00-'::;
:::Jllw
~CJO
f-ZOO
Z-
Q~~
[0(1')
Of->
w~C3
b~"'
Z::i~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~..Jilam Bradl~II~i1I1i\'fifl
1 ST 0 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that 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 mar jage state. / 17 / \ -
21. SIGNATURE OF GROOM ~ "L:'J" ~~ 22. SIGNATURE OF BRIDE ~ ' .
J;ECURRENTNA ~~~".-.I---L"
23. SUBSCRIBED AND SWORN TO BEFORE ME ~ .
SIGNATURE OF TOWN OR CITY CLERK ~ .y .oJ ..f) ~ - DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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
COuNnoutehcss
CITY !TOWN! '\IappiAger
DISTRICT ·
NUMBER~ 368
REGISTE
NUMBER 42
1. A FULL NAME
CURRENT SURNAME
0-
N
8 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 41 ()"61 1885
2. RESIDENCE A'N "TATE) B. D~ss
C. ~~6CK ONE 0 CITY..,iI TOWN 0 VilLAGE
SPECIFY ).Vappiflgcr
o STREET ADDRESS 24 Winthr-op Coun, Apt. E ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs..CJ NO
JlDH /O~Y /1~a1
3. A. AGE24
4. EMPLOYMENT
3B. DATE OF BIRTH
W
f-
<(
f-
'"
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Main Ceur-se Catering
5 PLACE OF BIRTHD~~~...oTtI~AeSSee
6. FATHER
~
:>
<(
c
W-
ClLL
:5LL
~<(
Z
~
o
t:
>
f-
o
A. NAME V'Jillianl Sullivan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Clizabeth Ruggieri
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o g
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
D
(2) 0 DEATH
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 ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0:
W
m
::;
::J
Z
a
Z
<(
f-
UJ
UJ
0:
f-
'"
w
UJ
Z
W
u
::i
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADORES
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
2f 2ce6
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE
MAILING ADORES:;;
. SALlc;~U;
STREET CITYfTOWN
30 WITNESS TO C;;~EMONY
NAME (PRINT) i~lq,M-- ~C~ae(e(
SIGNATURE ~ ~ (J,. .,g~
DOH.9B (11/98)
~1"'1~ rl&..C::; I'IUIVII:u:n
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
-.J
11. A.
FROM THE BRIDE
FULL NAME Kri~MP Marie Z~'ltR~
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE~~.~~~
(OPTIONAL. SEE REVER
D. SOCIAL SECURITY NUMBER 6707
12. RESIDENCE AN Y B.(llltrhj:Ot;lS
(STATE) ~MTvr
C. CHECK ONE 0 CITY ti!'l TOWN 0 VilLAGE
AND ~IU .
SPECh..applf.lger
D. STREET ADDRES~4 Winthmp C::ourt, Apt E ZIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
13. A. AGE24 13.B. DATE OF BIRTH g1 ti 1 sb?
MONTH DAY ~AR
14. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESsMontevp-rr:lp. Rp.~hmrRnt
15. PLACE OF BIRTHN(~"JJb&~~l}~~t~l~
16. FATHER
A NAMEKenneth Zav.ory
B. COUNTRY OF BIRTft I 5 A
17. MOTHER
A. MAiDEN NAME Ann Reaech
B. COUNTRY OF BIRTfGermany
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
05
03
2006
07
01 2006
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY '^lfCT('He;1
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)