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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shane Wlliam ~den
FIRST MIDDl
COUNTY DutchMs
CITYITOWN w.pplnger
~~J~~CRT 1_
~5~lgJ~R 128
1. A. FULL NAME
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
0-
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)1~" ~n1"'''g
D. SOCIAL SECURITY NUMBER -~~-~~-
2. RESIDENCEA. ~T~ork B.~
C. CHECK ONE 0 CITY f!I TOWN 0 VILLAGE
AND 'AI- .
SPECIFY V~pp,..
D. STREET ADDRESS 609 Papule ~everd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH M~ /~iy /1yi16
4. EMPLOYMENT
A. USUAL OCCUPATION B8rtender
B. TYPE OF INDUSTRY OR BUSINESS C. I. A ~ America
5. PLACE OF BIRTH ~IF~Arork
6. FATHER
A. NAME Harold Wlllam .....den. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME A....... .IAnnIfAr' 01 AmbrMlo
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
o 0
L 0 SUPPLEMENTAL FILE
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DEATH
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FROM THE BRIDE
11. A. FULL NAME Amanda Rtl7Anne Miller
FIRST MIDDLE
CURRENT SURNAME
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 DIVORGED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~den
(OPTIONAL - SEE REVERSE) 131 ~ ~.,
D. SOCIAL SECURITY NUMBER ___~L
12. RESIDENCEA.N8wVork B. n,"~
(STAfE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND We .
SPECIFY ppnger
D. STREET ADDREss609 PQpuIe ~everd
ZIP 12590
o YES~ NO
1.976
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 29 13.B. DATE OF BIRTH n5 ~
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Tax Accountant
B. TYPE OF INDUSTRY OR BUSINESS CoIg&te Palmolive Co.
15. PLACE OF BIRTH ~lnA. New York
. ~~NTRY IF NOT USA)
16. FATHER
A. NAME Frank I. Miller
B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME ,",--till Ann CRt:pIno
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
o 0
DEATH
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
0 0 1ST 0 0
a: 0 0 2ND 0 0
W
lD 0 0 3RD 0 0
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TIME MONTH
YEAR
MONTH YEAR
11:42AM 09
PM
30
2005
11 28 2005
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED~ L,
A. STATE NEW YORK B. COUNTY
C.
(j c ~ r/-e- r
IC-~'-()S-
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SPECIFY
o TOWN OF 0 VILLAGE OF
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SIGNATURE ~