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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rnhp.rt pl'lrKp.r Hp.n~h8~ \Ir
FIRST MIDDLE ' CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY n. dr:hp.!<:~
CITYfTOWN Wl'lppingp.f
~~J~~C~ 136~
~5~~J~R 59
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME K p.ni" Filp.p.n Fi~r:hp.r
FIRST MIDDLE
CURRENT SURNAME
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hen5haVtf
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER n7'_~rl-7~~Q
12. RESIDENCE A. N%TATEl B. n(htt~f~~
c. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY au; ep.p~le
D STREET ADDRESS '9 Fdgar ~treet ZIP 1 '~n~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [!" NO
13. A. 'AGE 28 13.B. DATE OF BIRTH --}o1rrH ,., tAY t9~8R
14. EMPLOYMENT
A. USUAL OCCUPATION NlJr~e
B. TYPE OF INDUSTRY OR BUSINESS Vl'l~~Rr Arnther~ Mp.d c.:ntr
15. PLACE OF BIRTH pll'linvip.\II' NP.\II' York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME F'dwRrd.1 Fischer .Ir
,
B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME EileeR OrugaR
B. COUNTRY OF BIRTH II '5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 '!:I-~R-QRQ7
2. RESIDENCE A. N~ATE) B. ~e!::~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 4'5 All Angel~ Hill Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 26 3B. DATE OF BIRTH MJl~ / 3Al
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS NP-Whurgtl Ni!::~Rn
5. PLACE OF BIRTH r:Rrmp.1 Np.w Ynrk
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Rohert P HenshRw, Sr
B. COUNTRY OF BIRTH I ) ~ A
7. MOTHER
A. MAIDEN NAME Diane Herbold
B. COUNTRY OF BIRTH I J '5 ".
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
125~3
YES ~ NO
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DEATH
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DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3)0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 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. ~ _ ~ ~.
21. SIGNATURE OF GROOM 22. SIGNATURE OF BRIDE ~ _llln "" --~
~ USE CUR NAME ~
DATE 07/05/2005
This license authorizes the marriage in New York State the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11 to perform marriage ceremonies within New 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
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{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
AM
12:28PM
2005
09
03 2005
07
06
ZIP
TATE
27. TYPE OF CEREMONY
O~GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY])v ~,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
TITLE
~VIFIt~Nl:;)
-
~C1 A,,,~
SPECIFY
~~"& ,(,COE.-
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)