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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
steven R ~.
FIRST . '~DDLE"
l
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY out.ctt-
CITYfTOWN Wappl~
~5';::f: 1388
~5~~~R 76
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME ~1F8 C R~
CURRENT SURNAME
CURRENT SURNAME
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~~~r~~~~e~~~
D. SOCIAL SECURITY NUMBER 1 QO.7G-87 49
12. RESIDENCEA,~AXpr:k B. ~
C. CHECK ONE 0 CITY 0 TOWN II VilLAGE
AND
SPECIFY 81 act-fUl"
D. STREET ADDRESS 129 Bu~ Court ZIP 10511
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE29 13.B. DATE OF BIRTH a1NTH ~DAY 1e7iAR
14. EMPLOYMENT
A. USUAL OCCUPATION NlJftIA
B. TYPE OF INDUSTRY OR BUSINESS cerecore NetloneI
15. PLACE OF BIRTHIIe~ DftrtIIIIlII
~NOTUSA)
16. FATHER
A. NAMESilv~ Poct'igl aes
B. COUNTRY OF BIRT~.
17. MOTHER
A. MAIDEN NAME Alcina Cunha
B. COUNTRY OF BIRT~
lB. NUMBER OF THIS MARRIAGE ...f
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
~
I-
en
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)~7ft n.-rr7
D. SOCIAL SECURITY NUMBER ~I-
2. RESIDENCE A. lIJ.ut~orIc B. ~N
~) ~
C. CHECK ONE CITY 0 TOWN 0 VILLAGE
AND ~a.;11
SPECIFY ...--.
D. STREET ADDRESS 231 Fl'Mmont street ZIP 1NiAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? t!l YES 0 NO
3. A. AGE 35 3B. DATE OF BIRTH M~ / ~Y /1;iZD
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS AdwtntW'l t""..nrnfM
5. PLACEOFBIRTH~I\'~~VNk'
6. FATHER
A. NAME stBte ~.
B. COUNTRY OF BIRTH Vt.pN8
7. MOTHER
A. MAIDEN NAME Vena Mad. ~
B. COUNTRY OF BIRTH VlIIDStN8
B. NUMBER OF THIS MARRIAGE }
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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 B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 06 / ~ C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
1ST. nAID8I2OO2 Carmel, NewVNk' ~ 0 1ST 0 0
~ 0 0 ~ 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage state. ",,J "A~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~ ~-
USE CURRENli il\ME
23. ~~~~~~~DO~N~o~~06'~ ci;~g~~~~E DATE 07nRnM5
This license authorizes the marriage in New York Sta of the bride and groom named above by any person authorized by New York Domestic
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(PRIN~) -
SEAL SIGNATURE. . . . DATEOZl28I2OD5
'-..-' M~Ufc ~ ~d. W8ppinaer Falls, NY 12590 0:10 AM rn
STREET ~WN STA;'E ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYP F CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O' RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND"'" .t'
PLACE INDICATED. PM 0 J 9 0 OTHER, SPECIFY
:~::: ~!i:i~ii ~t~:
MAILING ADORE S ~
V(!)rrl N I
CI fTOW
DEATH
DEATH
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YEAR
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YEAR
MONTH
YEAR
TIME
MONTH
29
2005
09
26 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY MJr:5Tt({{s'"ul.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF VVILLAGE OF
SPECIFY ()<'{11.f I t{4 JI V 16 rt Z-
<9
/6 )12.--.
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE ~
