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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
..ceIr I(llni~
FIRST MIDDLE
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
..COUNTY [>tdcltr-
CITYfTOWN Wappng;v
DISTRICT 1368
NUMBER
~5~I~J~R 73
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Da1ii~le Petrici!D~,mn
11. A. FULL NAME
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~JN~~~~~~~e~~S~n.- Kunidci
D. SOCIAL SECURITY NUMBER Q64..6&.238R
12. RESIDENCE A. ~.:t0Jk B. ~Sl
C. CHECK ONE 0 CITY [jll TOWN 0 VILLAGE
AND 'a.... .
SPECIFY YlRIPPrp'
D. STREET ADDRESS 32 ~""' ("~ ~nAd ZIP 12!\M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES flit NO
13. A. AGE "'Vl 13.B. DATE OF BIRTH Q1_ ~ ~.(..,~
A" ONTH WDAy lVI.m.R
14. EMPLOYMENT
A. USUAL OCCUPATION Office Avrant
B. TYPE OF INDUSTRY OR BUSINESS D ttc~ 1- eo,nm Cd
15. PLACE OF BIRTH ~_~~)
16. FATHER
A. NAME Robert Lot is Perria
B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME PlItricie Ann Connell
B. COUNTRY OF BIRTH I I SA
18. NUMBER OF THIS MARRIAGE 1
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER ()R;..sn.A~
2. RESIDENCE A. NM),odr B. ~I
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND .al- .
SPECIFY vvapp,..
o STREET ADDRESS ~ ~Am ("~ ~ftAd ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0 YES flit NO
3. A. AGE 32 3B. DATE OF BIRTH M~ / ~ / 1R72
4. EMPLOYMENT
A. USUAL OCCUPATION FrNirnnmf!"hll ('~...nt
B. TYPE OF INDUSTRY OR BUSINESS Enviml'9~ ft N V
5. PLACE OF BIRTH
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6. FATHER
A. NAME 7.nnn11C7 t(llrUcIri
B. COUNTRY OF BIRTH Pde,.,t
7. MOTHER
A. MAIDEN NAME Irene ~
B. COUNTRY OF BIRTH PoIlrvt
8. NUMBER OF THIS MARRIAGE 1
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
(2) 0 DEATH
B. HOW DID LAST .MARRIAGE END? (3) D.DlVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
MONTH DAY YEAR
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
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1ST
2ND
3RD
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of my kn
as to my right to enter into the marriage state. .
21. SIGNATURE OF GROOM ~
USE CURRENT NAME
DATE lf7127nm5
bride an groom named above by any person authorized by New York Domestic
State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in ew York State of th
Relations Law ~11 to perform marriage ceremonies within New Yo
o If checked, this license is to be use
24. TOWN OR CITY CLERK
~
{ SEAL}
~
YEAR
YEAR
MONTH
TIME
MONTH
NAME (PRINT)
DATE (flmrxn5
09
25 2005
10:01 AM 07
PM
28
2005
ZIP
STATE
27.. TYPE OF CEREMONY
O~GIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o ,,,yO; ,DLrow~o' ~'o,
SPECIFY ,JL1!t!1Ef/~iC.s ~
CI
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
R, C. fkJ~T"
8' I~/()S'
I~()
TITLE
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE~
DOH.98 (11/98)