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CITYrrOWN Weppla,ger
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMtlt:H
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
KfNi" Tnrm8}t
FIRST MIDDLE
FROM THE BRIDE
11. A. FULL NAME ValAriA .JAII" RAtmA
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE T 0fTIlI"V
(OPTIONAL - SEE REVERSEr
D. SOCIAL SECURITY NUMBER lJ73..S2.7A04
12. RESIDENCEA.NMAtVork B, n..tm-
~A"fE) ~
C. CHECK ONE 0 CITY flt TOWN 0 VILLAGE
AND 0- uooha.--i
SPECIFY.-,.... .~e
D. STREET ADDRESQ1 She8fe Road Lot 1:125
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)11 ~ ~1lI .7:r!....,
D. SDCIALSECURITYNUMBER __~_~.!.
2. RESIDENCE A. ~;Y,ork B. ~
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND D-uooha...-i
SPECIFY .-..."V ....~e
D STREET ADDRESS 621 She8fe Road Lot 1:125 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
01 /n7 /19Rf]
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGEA~ 13,B. DATE OF BIRTH n7 ~
MONTH DAY
ZIP 12601
o VES~ NO
1AR?
YEAR
3. A. AGE A5
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Auto Mecharic
B. TYPE OF INDUSTRY OR BUSINESS Dls8b1ed
5. PLACE OF BIRTH Mount KIsco New York
(CITY, STATElCOUNTR~ IF NOT USA)
6. FATHER
A. NAME \Mlliam Tormey
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME 11'-'-1 Kelly
B. COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 2
14, EMPLOYMENT
A, USUAL OCCUPATION Un . E:mpqyed
B, TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH'M)Ite PlIII,. New York
(CITY, STATElCOUNTR~ IF NOT USA)
16, FATHER
A. NAMEJohn Bst.chIe
B, COUNTRY OF BIRTJJ S A
17, MOTHER
A. MAIDEN NAME tean Bell
B. COUNTRY OF BIRTJJ S A
18, NUMBER OF THIS MARRIAGE 2
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? 02 /05 /1997
MONTH DAY YEAR
0, ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 1ST 02JD5f1997 P~kBe.psie., New York
o 2ND
o 3RD
o 4TH
d belief that the information I provide
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 13 /2005
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST ~1~J~~~I!'_~I'Ity. _~'I'CII1c. . ~
~D 0
3RD 0
4TH 0
I, being duly sworn, depose and say, that to the best of my knowledge
as to my right to enter into the ma' sta,
DEATH
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DEATH
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2, SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWOR EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within ew 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
{ } NAME (PRINT) John
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09I.26l2OO5
'-y-I M~W&lS Falls NY 12590
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11
25 2005
DATE
by New York Domestic
MONTH
YEAR
.24 AM 09
PM
27
2005
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
o OTHER, SPECIFY
~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~ ~ ll.D'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF,.k(ro~1N OF 0 VILLAGE OF
SPECIFY[l t. J\ IJ; ,. ~-Pr
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I- 29.0FFICIANfJ1; ~~ V\l~' ~
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~ MAILING ADD S ~ ~ l
a: ~?.() mrttd/ehl..ls" 7?:f. Wo..ft/;~-e..rs j)y /'d-s:-qlJ
W ....... STREE1 - CITYrrOWN ,... ---"-V STATE ZIP
o 30. WITNESS TO C17REMONY 31. WITNESS TO CER MONY
NAME (PRINT) ~ IAl D./t NAME (PRINT)
SIGNATURE~