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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
A FULL NAME Chri~tnphAr ,ln~Anh nurkin
FIRST MI~
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(THIS SPACE FOR STATE USE ONL Y)
tVfr /Lsf-P
COUNTDI d~hA~~
CITYlTowWappingAr
~Jr~~~c4 368
REGISTE136
NUMBER
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
CURRENT SURNAME
11 A. FULL NAMEfa",mv nAni~A ~tAI1bAr
FIRS'f MIDDLE
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENOrinluud
C. SURNAME AFTER MARRIAmDurkin
(OPTIONAL. SEE REVERSE,l
o SOCIAL SECURITY NUMBER 414-2:\-4R09
12. RESIDENCE~ew Ynrk llutchp_~s
(SRrr) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
AND '11" .
SPECIFW.applnger
o STREET ADDRES16 A Alpine flrive
ZI12590
o YE~D NO
191'0
DAY YEAR
CURRENT SURNAME
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B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSi,l
o SOCIAL SECURITY NUMBER uR:\..flR-~9'4
2. RESIDENCE .tNA'TX~rk BDlt~~~f~
C CHECK ONE 0 CIT'*'D TOWN 0 VILLAGE
AND ,., -
SPECIFYlflfappmger
D. STREET ADDRES{J *' A Alpine f)rive zIP1 '~90
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 yE"!'D NO
3 A. AG23 3B DATE OF BIRTH "_...~.... .-4"1 AQR1.
~
4. EMPLOYMENT
A. USUAL OCCUPATIO~ndnw & Ooor Installer
B TYPE OF INDUSTRY OR BUSINESM~ c.:arthy c.:nntr9~tnr
5. PLACE OF BIRTP~ft~i!~I}'~I~Arnrk
6 FATHER
A NAMEWilliam Martin nurkin
B COUNTRY OF BIRT" J ~ A
7. MOTHER
A MAIDEN NAME Lisa Ann Incoronato
B COUNTRY OF BIRTHl J S A
8 NUMBER OF THIS MARRIAGE1
16. FATHER
A NAMf.very Drinkard
B. COUNTRY OF BIRiJ S A
17. MOTHER
A. MAIDEN NAMHelen 0'" Eddy
B. COUNTRY OF BIRiJ S A
18. NUMBER OF THIS MARRIAGEl
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPoRATED VILLAGE?
13. A. AGM 13.B. DATE OF BIRTH nQ <<
----':;ONTH
14. EMPLOYMENT
A. USUAL OCCUPATIOUnemployed
B TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRrCullmRn Alahama
(CITY, STATE/COUNTRY IF NOT USA)
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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) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B HOW DID LAST MARRIAGE END? (3~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C. DATE LAST MARRIAGE ENDED? 03 /29 A004
MONTH DAY YEAR MONJjI DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 'W(J YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST 0 0 1 slll::\1291701l4 nulchAss Co . NAW York 0 ....[]
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly SWDrn, depose and say, that to the best Df my knowledge and belief that the infDrmatiDn I prDvided is true and that I declare that nD legal impediment exists
as to my right to enter into the marria!l ate. --.... .---
" '."'""~'l'.~". ""0",""' 0'""" .=<~ ~~
23 S SCRI~ED AND SWO~~ T BEFORE ME ,~RENT NAME
S~A TURE OF TOWN OR crt-: .cLERK ~ DATE 08/ 10/2005
Tnis license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
_~elations Law !l11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
W .~ 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
en
z ~" ,24 TOW['J OR CITY,CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W { ..'. } 'NAME (PRINT) . Ma ters TIME MONTH
~ SE~L,. SIGNA'TURE ~ DATD8/1012005
~ ~fciaRE Falls NY 12590 8
STREET /TOWN STATE ZIP
I CERTIFY TflAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
THE MARRIAGe OF THE PER-
SONS NAMED 'ABOVE Oi'lTHE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED PM
DEATH
DEATH
o
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
o
C. DATE LAST MARRIAGE ENDED?
YEAR
09 2005
28 PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
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29. OFFICIANT
NAME (PRINT)
TITLE
o CITY OF 0 TOWN OF 0 VILLAGE OF
DATE
SPECIFY
SIGNATURE ~
MAILING ADDRESS
CITYiTOWN
STATE
ZIP
31. WITNESS TO CEREMONY
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/9B)