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COUNTY [)~
CITYITOWN Wa.pplnger
DISTRICT 1. ~~o
NUMBER ~
~3~~J~R 25
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John E. Frederick. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
SUPPLEMENTAL FILE
FROM THE BRIDE
Gabriella Mierisch
MIDDLE CURRENT SURNAME
--1
Lo
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1'\01'\-72 5190
D. SOCIAL SECURITY NUMBER Ui7\I"-
2. RESIDENCE A. New Yark B. Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~~CIFY Hiahland
D. STREET ADDRESS 392 Crescent Avenue
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Frederick
(OPTIONAL - SEE REVERSE) 11 n .72 1103
D. SOCIAL SECURITY NUMBER - ~-- - --
12. RESIDENCE A. N(~E~ork B. 9c:~~ess
c. CHECK ONE 0 CITY OIllifOWN 0 VILLAGE
AND W .
SPECIFY appnger
D. STREET ADDRESS 12 Joan Lene ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D'" NO
M /?~ AQ7R
MONTH DAY YEAR
ZIP 12528
o YES rfNO
E.
13. A. AGE ?f;
14. EMPLOYMENT
A. USUAL OCCUPATION Hairrt~
B. TYPE OF INDUSTRY OR BUSINESS Cosmopolitan Salon
15. PLACE OF BIRTH p~eb New York
(CITY, S TElCOU Y IF N T USA)
16. FATHER
A. NAME Donald James Mierisch
B. COUNTRY OF BIRTH USA
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ?5 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Relph C. Herman. Co.
5. PLACE OF BIRTH pt'llll'lh~~, New York
(C~~~~NOTUSA)
6. FATHER
A. NAME John EdNard Frederick
B. COUNTRY OF BIRTH USA
13.B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME O"brA I ...... erftWn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME Unda Made Meroedante
B. COUNTRY OF BIRTH l.J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAqE 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
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
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 besl of my knowledge and belief thai the information I provided is true and thai I declare that no legal impediment exists
as to my right to enter into the marria s e. ~- \ n ~~. . L
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~ uMa ~ t--
USE CURRENT NAM
DATE 04/1RnlY15
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York SI e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
. 0 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
~
{ SEAL }
'-.,-I
YEAR
MONTH
YEAR
TIME
MONTH
NAME (PRINT)
SIGNATURE ~
MAILING ADI?RESS
AM
03:01PM
04
19
06
17 2005
ZIP
SA E
27. TYPE OF CEREMONY
0.lCl' RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY [Jkrf.rkJkr
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ))t TOWN OF 0
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
UtJ5'
k~,,-d
5)/3/ oS-
SPECIFY
rorl-IG<...~
TITLE
VILLAGE OF
DATE
AlY
STATE
z... ~~{p~z...
ZIP
31. WITNESS TO CEREMON
t
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~
DOH-98 (11/98)