144
~
A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
UarIc ~ ArvtM1uvti II
MIDDLE CURR~NT SURNAME
FIRST
FROM THE BRIDE
MW. 8eIh C___ SURNAME
I
COUNTY DuIchess
CIT\,YTOWN ~
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'~G~I~J~R 144
(THIS SPACE FOR STATE USE ONL Y)
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11 A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C S~~~~~~M\~E~~t:e~~SE)AndenIaR
D. SOCIAL SECURITY NUMBER 59~ 11-.2474
~eI.er
VILLAGE
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 181"""-
SOCIAL SECURITY NUMBER ---~~
2 RESIDENCE A. New York B R-iIIaeI:
(STATE) . (coomvr
C CHECK ONE 0 CITY []!frOWN 0 VILLAGE
~~~CIFY North "'....-m.Jah
D STREET ADDRESS 4 RIver Cf'I-'" OrNe
12. RESIDENCE A ".EY-
C ~~6CK ONE 0 CITY O-'OWN 0
SPECIFY NcxIh Greenbu8h
D. STREET ADDRESS 4 RIver Chlse DmIe ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
McG6 / 89
12144
YES YfNO
/19110
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 38. DATE OF BIRTH
ZIP 12144
o YES ~NO
13 A. AGE 24
14. EMPLOYMENT
13.8. DATE OF BIRTH
MO
4. EMPLOYMENT
A. USUAL OCCUPATION QRIGlnIte student
8. TYPE OF INDUSTRY OR BUSINESS R. P. I.
15.PLACEOFBIRTH ~R~~oIIA8
16. FATHER
A. USUAL OCCUPATION I;rVnRAI'
B TYPE OF INDUSTRY OR BUSINESS I. B. M
5. PLACE OF BIRTH ~1ftA1L ~ VorIr
~l-ln'MtutA)
6. FATHER
A NAME .-rtr f;mAI' ~
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Klmbllty Ann Thom.
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
A. NAME Jeny Ranald Cf1iIII8Y
B. COUNTRY OF BIRTH USA
17 MOTHER
DEATH
A. MAIDEN NAME Shell H.n 1 leis ~
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
o
(2) 0 DEATH
o 0
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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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o 0 3RD 0 0
o 0 4TH 0 0
ledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ r1~---"." ./'
~ US~ENTNAME
4TH
I, being duly sworn, depose and say, ttlapo the best of my k
as to my right to enter Into th~ tat~
21 SIGNATURE OF GROOM ~ "/
us CUR
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with 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
~
{ } .~;r~,(e~INT)
S EA~,'s'IGN:TU" ..,.
. ' MAILING ADDRE
~ ST .'
I .ClO!'lTIFY TH~ll. SO. LEMNIZED
T!-lE' MARRI~C.F .oF THE PER.
SONS NAMED ~V~ ON THE
OA TE ANQ,.,ff IRE :n,M!i' MID
IJtlCEIN[J1'C'ATED '-:- " . " '--',
t.~ ~~-;- -'!i,'~'T '_;~l;. i f~,~ I.
29.0FFICI~~.'''''''i,j,.'.-,. "'..~.
NAME JPRIN.r;.. " ~. , ~' '
: '.:' "r.!':",,,,'
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. -,' ,.'.- . (,',
TIME
MONTH
YEAR
YEAR
DATE 1211Y2004
AM
PM
12
ZIP
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
TITLE
DATE
SPECIFY
STREET
30 WITNESS TO CEREMONY
CITY/TOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~