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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM /J
.~J:~D~~
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE r
(OPTIONAL. SEE REVERSE) ,
o SOCIAL SECURITY NUMBER 17~
2 RESIDENCE A, ~ B,~
C CHECK ONE f1/i!J CITY 0 TOWN 0 VILLAGE
~~~CIFY ~
D, STREET ADDRESS 194 \AIfomIflG street ZIP 18407
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? t!! YES 0 NO
3 A AGE 45 3B DATE OF BIRTH M~ / \ly / '\liD
4. EMPLOYMENT
A, USUAL OCCUPATION ~
B. TYPE OF INDUSTRY OR BUSINESS RqAdl--.y ~prAIIIII.
5, PLACE OF BIRTH ('~~ ~
(CITY, STATE/COUNTHY IF NOTus:<Ir
6. FATHER
A. NAME John ~ RQgRn
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Co.'lIt8r.ce VeronIc8 Warde
B, COUNTRY OF BIRTH QfilIlIIl!!d ArItIAn
B. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? 11 / 22 /199S
MONTH DAY YEAR
D. 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST OMJ7I1MO ~.,gh, ~8n1El
o 0 2ND 11l2211993~,\ NewYnrk
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true and
MONTH DAY
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
COUNTY ~.
CITYfTOWN ~"08f
~~I~~kCRT1~
~5~I~J~R 82
A FULL NAME
CURRENT SURNAME
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9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C, DATE LAST MARRIAGE ENDED?
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1ST
2ND
3RD
4TH
I, being duly sworn,
as to my right to ente
23. SUBSCRIBED AND SWORN TO B ME
SIGNATURE OF TOWN OR CITY CLERK ~ DAT
This license authorizes the marriage in New York Sta authorized by
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
21.
CI
26. ;;;OLEMNIZATION OCCURRED
. IME MO, DAY YEAR
STREET
I CEfHlFY THAT I SOLEMNIZED
TI;lg:"MARRIAGE OF THE PER.
~S NAMEPJlBOVE ON THE
DA1'E ANlNAJ'THE TIME AND
~CE IND19ATEf '; ''''t''
.-. ... '. ',f t .
_..'....'~'~...-'._'T.
?9'OF~~' T--:"~.~;:' -c, "'. '," "
NI'J>AE (PPl ~/' 1 "t' 'j'''l'':'. I .
, . ,...,f~;. ~, "-0f
....... ....:~:-..~;~.,.:E ,r",~.. ':,
SIGNJH'URE'.r; ::-":~(, " ... /
MAILh-I~ADDRESS~, ~~'; . ,~ /
STR~E~~~A --O;''-0'(~ ~ITYiTOWN
30. WITNESS O.yEREMONY.'"
AM
PM
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
I
v1rl;~3bk
NO t 1l/}~iJ
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karin MafiA ~
FIRST ~O~
.-J
11. A FULL NAME
CURRENT SURNAME
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~~N~~E~~t~~e~~s~ - Ragen
D. SOCIAL SECURITY NUMBER (]66..AI. 7149
12 RESIDENCEA~A~ B~
C, CHECK ONE 0 CITY fiI! TOWN 0 VILLAGE
AND
SPECIFY ""-PP..... .
D. STREET ADDRESS 12 CarmIne DrIve ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
~NTH Jf80Ay ~
13. A, AGE44
14, EMPLOYMENT
A. USUALOCCUPATION~~
B. TYPE OF INDUSTRY OR BUSINESS I-\fdA Park SM
15. PLACE OF BIRTH.~ Per~
(CIi'Y7~NTRY IF NOHISA)
16, FATHER
A. NAME~T ~
B. COUNTRY OF BIRTrU S A
13.B. DATE OF BIRTH
rw
17, MOTHER
A. MAIDEN NAME Mary C81bedne Nally
B. COUNTRY OF BIRTrU S A
lB. NUMBER OF THIS MARRIAGE 3
DEATH
o
DEATH
o
(2) 0 DEATH
YEAR
r!
o
~
22 SIGNATURE OF BRIDE ~
o
York Domestic
TIME
MONTH
YEAR MONTH
YEAR
ZIP
AM
03:32 PM 08
06
2005
10
04 2005
2B. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
DATE
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~