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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wllhlm .John l-larm~
FIRST MIDDLE
19. 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
C. DATE LAST MARRIAGE ENDED? 12 / 18 /1987
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? L:'r 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
r!!! 0 1ST 1211811M7 Mleml, Florida 0
o 0 mo 0 0
o 0 3RO 0 0
o 0 4TH 0 0
knowledge and belief that the informatiDn I provided is true and that I declare that no legal Impediment eXists
2 SIGNATURE OF BRIDE ~ .~, IN k ~
~
DATE ~
of the bride and groom named above by any person authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutm---=.
CITYIT~N Wapplrow
~~J~kCJ 1~
~5~I~J~R 54
1. A FULL NAME
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. S6~~~I~~;~R~T~~U~~~~RSE)~104
2 RESIDENCE A New VnrIc B. n.~
(STATE) ~
C. CHECK ONE 0 CITY If! TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 37 A Alpine DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
in /M /1~
MONTH DAY YEAR
3. A AGE 50
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS L..ocaI Union #3
5. PLACE OF BIRTH Yonkers. New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
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A. NAME George Francis Harm~
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME k>A" "ell' ..~
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
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
C. DATE LAST MARRIAGE ENDED? 05 / 30 / 2003
MONTH.J DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? L:'r 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
MlW2CIm ~~,., NAWVork
DEATH
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{ } NAME (PRINT)
SEAL SIGNATURE ~
'-.,-I M~~D
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.l
11. A, FULL NAME ~inner Lhe8 \ANclle
~ -"-'MlfiDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT VVnhlmb
c, SURNAME AFTER MARRIAGE "'rm~
(OPTIONAL - SEE REVERSE) 131 ",1') ~~
D. SOCIAL SECURITY NUMBER ---~
12. RESIDENCEA.fWIMIVork B. Dlltrh~
~A'!ti (COUNTY)
C. CHECK ONE 0 CITY '!I TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D STREET ADDRESS 37'" Alpine ~e
CURRENT SURNAME
ZIP 12590
DYES!! NO
~
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 48 13.B. DATE OF BIRTH M 118
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Resjsterod Nurse
B. TYPE OF INDUSTRY OR BUSINESS state or New York
15. PLACE OF BIRTH DN It'IhlMArtcle. New York
. (~A~~1:TRY IF NOT USA)
16. FATHER
A. NAME Leonard James Wablrab
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Vll's;nia TnI'fAM
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 2
DEATH
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
TIME
MONTH
YEAR
MONTH
DAY
YEAR
DATE ~
Falls NY 12590
ZIP
AM 06
02:22 PM
08
28 2005
30
2005
STATE
27. TYPE OF CEREMONY
.~IGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED1 I J, I ..
A. STATE NEW YORK B. COUNTY ~i
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFYY'{\6\'")--4 Q c ~ ~ -
TITLE
'f>
NAME (PRINT)
SIGNATURE ~