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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.15 E~~II~oma, II CURRENT SURNAME
CURRENT SURNAME
I
(THIS SPACE FOR STATE USE ONLY)
COUNTY f"t~
CITYfTOWN WAppi~
~lf~~~c~ 1368
~5~lgJ~R 18
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~8nie MirltAf(EDaniels
11. . A. FULL NAME
"-
N
a.. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I uoma
(OPTIONAL. SEE REVERS~
D. SOCIAL SECURITY NUMBER Q52-7().6Q79
12. RESIDENCE A. NewA~)ork B. ~s
C. CHECK ONE 0 CITY ... TOWN 0 VILLAGE
~~~CIFY FlShldll
D. STREET ADDREss6 Mnuntain View KnDlls, Ar:t- ZIP 1%~.t
E. IS RESIDENCE WITH~N liMiTS OF CITY OR INCORPORATED VILLAGE? 0 YES fl NO
13. A. AGE 22 13.B. DATE OF BIRTH n7 44 19B':l
"'lfAONTH DAY ~R
14. EMPLOYMENT
A. USUAL OCCUPATION Uf'P!I"'pryM
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~~YAA)
16. FATHER
A. NAME BryAn..,.",., f1Ani~
B. COUNTRY OF BIRTHU $ A K.'
17. MOTHER
A. MAIDEN NAME Tracy ~ Katz
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
a. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 097 ~ 1056
2. RESIDENCEA.N.t~OIt' B. ~
C. CHECK ONE 0 CITY i!t TOWN 0 VILLAGE
~~~CIFY FlAttkill
D. STREET ADDRESS 6 Mountain View Knolls, Apl.zIP 1~.t
E. IS RESIDENCE WITHIN UM~S OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 21 3B. DATE OF BIRTH M~ / Q;l / 'if4
4. EMPLOYMENT
A. USUAL OCCUPATION HnmP.lAnd ~Irit.y
B. TYPE OF INDUSTRY OR BUSINESS ~ Of NAW Vf'II'I(
5. PLACE OF BIRTH 1~~XFCllFuSA)
6. FATHER
A. NAME .IAm.- s:'riwArd IllnmA
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME patty Anne VVltght
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
DEATH
o
o
o
o
('
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
at no legal impediment exists
1ST 0 0 1ST
~ 0 0 ~
3RD 0 0 3RD
~ 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 a d that I declar
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
23. ~::~~T~~~DO~N~o~06'~ 6'ivBg~;i~E DATE n~
This license authorizes the marriage in New York St person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is t be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATIOWPERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-'
YEAR
MONTH
DAY
YEAR
TIME
MONTH
NAME (PRINT)
SIGNATURE ~
MAILING ApDRESS
DATE~
AM
01:06 PM 03
2006
05
19 2006
21
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYINRA.flJ...wk
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF g TOWN OF 0
STAT
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 ~ OTHER, SPECIFY
CI
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
If:~ \ A 11 '3 () DIo
29. OFFICIANT q~ ~ t::" J ..,-.11
NAME (PRINT) ~ ~~." 1 l' v: ItJl\ \I Y'
SIGNATURE ~ ~ JvNb
MAILING ADDRESS
fo 6)(' i)-I W'{~)(.Sh{)t#-y'\
STREET CITYfTOWN
30. WITNESS TO,CEREM Y
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED AaOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
VILLAGE OF
SPECIFY
y trY1< tv IN ()
STATE
NAME (PRINT)
SIGNATUR