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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vignt MicballrEederico CURRENT SURNAME
I
STATE FILt:. NUMD~n
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutch!!!
CITYrrpWN 'NappIng<<
~~J~fFi 1368
~5~lgJ~R 70
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11. A. FULL NAME ChridnA RtfAm
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT [)NISI Unnir.a
C. SURNAME AFTER MARRIAGE FedArir.n
(OPTIONAL - SEE REVERSE) 1 02"" .ft ~1'"
D. SOCIAL SECURITY NUMBER --~_!!
12. RESIDENCE A.tJ.w VtVIr B. nil.""'"
~A~l ~
C. CHECK ONE 0 CITY r1! TOWN 0 VILLAGE
AND 0- uooha..-i
SPECIFY -- - v ---v-e
D. STREET ADDRESs621 Sheafe Roed Lat 95 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13 A AGE 50 13.B. DATE OF BIRTH 11 ~ ..ai;A
. . ).1~NTH U.? DAY Ig~
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION SPI~.n A. USUAL OCCUPATION UnernplQyed
B. TYPE OF INDUSTRY OR BUSINESS Self Frnp'\lM B. TYPE OF INDUSTRY OR BUSINESS
5 PLACE OF BIRTH ~rIr NAIl ....., 15. PLACE OF BIRTH VnnkBP.;' New Vork
. ~RV I~ NOT USAr (CITY, STATE/l:ciiJN'i'RVTF Nci'i'USAl
6. FATHER 16. FATHER
A. NAME [)onliQir.k' FMWir.n A. NAME (".Juar1f!5 Rtfl!W8rt Minner1y
B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTHlJ S A
7. MOTHER 17. MOTHER
A. MAIDEN NAME Florenot R. S~ A. MAIDEN NAME Patdcle Anne Delener
B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTHI) S A
B. NUMBER OF THIS MARRIAGE 2 lB. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT DEATH DIVORCE CIVIL ANNULMENT
I) I) 1 0
B. HOW DID LAST MARRIAGE END? (3) ~ 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? 1~ / m / 1QQ1\ C. DATE LAST MARRIAGE ENDED? 06 / 16 /1988
MONTH DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
121031199'\ Por~' tW 0 1ST Ml1811988 WhIte Plein$, NewVark 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
elief that the information I provided is true and that I declare that no legal impediment exists
SIGNATURE OF BRIDE ~ f'\\. ~ .~. ii' ):} fJ::J) () ~
~ USE CURR~NT NA'if2-
23. SUBSCRIBED AND SWORN TO BEFORE ME rr7rv:.1'VtIV::.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE ", '~"\AhI
This license authorizes the marriage in New York Stat of the b ide and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is t e used only for the urpose of a second Dr subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME(PRINT)~~
SEAL SIGNATURE ~'" L.1"n~' DATE 07l2512OO5 TIME MONTH YEAR MONTH YEAR
MAILING ADDR S'. 2590 AM 26 2005 09 23 2005
'-v-I ST3R Middl..n1Rh Ad, ~_fallsr NYrAT1- ZIP 02:10 PM 07
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~ 2B. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- M<< ~
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND A. STATE NEW YORK B. COUNTY
PLACE INDICATED. 9 0 OTHER. SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LAGE ~ J I
ECIFY HI~/~ '1:1Jd!!
B. . BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1Q8..~~
2. RESIDENCEA. ~'t. B.~
C. CHECK ONE 0 CITY li!I TOWN 0 VILLAGE
AND ...._. uooh"--i
SPECIFY ..-nIV-_~..,.-A
D. STREET ADDRESS 821 AhMf8 RftAd l...ftt 95 ZIP 12801
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES If/:, NO
3. A. AGE61 3B.DATEOFBIRTH~
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I, being duly swom,
as to my right tD'ente
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29. OFFICIANT
NAME (PRINn
NAME (PRINn
SIGNATURE ~
DOH-98 (11198)