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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MgaeI SaRfoBlLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutcbes5
CITYfTOWN \Nappnger
BISTRICT 1368
' NUMBER
~Q~~~R 121
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME AI_ 8FOOke Q.rIP
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Smith
C. SURNAME AFTER MARRIAGE Q~nferd
(OPTIONAL - SEE REVERS!!l"'"
D. SOCIAL SECURITY NUMBER -431 7H115
12. RESIDENCEA.N.A~ B 8~n
C. ~~5CK ONE ,ljiI CITY 0 TOWN 0 VILLAGE
SPECIFY BordentaWn
D. STREET ADDRESs37 EestBuJllngton Street ZIP08505
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13 A AGE ~" 13.B. DATE OF BIRTH ftA /4 ...I-IlL
.. au "<<!l!!NTH '14 DAY ."4f'f!AR
14. EMPLOYMENT
A. USUAL OCCUPATION .......nt Manager
B. TYPE OF INDUSTRY OR BUSINESS VItamin SMp
15. PLACE OF BIRTH_,~USA)
16. FATHER
A. NAME Brian Keith Smith
B. COUNTRY OF BIRTfiJ S A
17. MOTHER
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER 129 6~ 1994
2. RESIDENCEA. N.~ey B. ~~
C. ~~5CK ONE ojI! CITY 0 TOWN 0 VILLAGE
SPECIFY 8afdentown
D. STREET ADDRESS 37 East e..Jllngton street ZIP 08505
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ill YES 0 NO
3. A. AGE 36 3B. DATE OF BIRTH MQt / '\Iv / 'Wi9
4. EMPLOYMENT
A. USUAL OCCUPATION Uelllenant
B. TYPE OF INDUSTRY OR BUSINESS Bureeu Of PrIsons
5. PLACE OF BIRTH DftIIt'Ih.,..,..,. NauI Yode
~N~
6. FATHER .
A. NAME A-vrnnrvt I RAnf()l1'l
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy R. HcmMII
B. COUNTRY OF BIRTH . USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) W DIVORCE (3) 0 ANNULMENT (2) 0 DeATH
C. DATE LAST MARRIAGE ENDED? MwfIl / ~ / ~1
D. ARE ANY FORMER SPOUSE(S) ALIVE? W 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
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A. MAIDEN NAME Sarah Unn BYleRl
B. COUNTRY OF BIRTt(J S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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B. HOW DID LAST MARRIAGE END? (3) rl! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Q2 / na / 1QQ1\
MONTH ~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? M'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
1ST O2I09f1995lwAston. Milne M' 0 lsT071J512OO1 811_ Maria, C8IifcImIe
~ 0 0 ~
~ 0 0 ~
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of dge and belief that the information I provided is true
as to my right to enter into the marriage t t .;.
21. SIGNATURE OF GROOM ~
'iI 0
o 0
o 0
'0 0
ediment exists
NATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE fSI21~
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within N 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
,-"-.
{ SEAL }
'-v-I
YEAR
YEAR
MONTH
NAME (PRINT)
SIGNATURE ~
MAILING ApORESS
TIME
MONTH
DATE ogr)7f)Q[]5
10:09 AM 09
PM
2005
11
26 2005
28
ZIP
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJ:;/~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Jl/..TOWN OF 0 VILLAGE OF
.- ~.....'" . v:.t,
SPECIFY LI9-~
1 't-cIV1L
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~
