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DIS-TRICT 1 ~o
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~Q~I~J~R 107
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher F. .lava
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
UHi A. Sucich
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE .JiJlvB
(OPTIONAL. SEE REVERSE) 1 nn J::D '7386
D. SDCIAL SECURITY NUMBER -~~--
12. RESIDENCEA. NewVork: B. ntdm_
"-(S'1'A'TE)' ~I
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND p.....lftha..-.-i
SPECIFY, ~._t-"e
D. STREET ADDRESS P. O. Box 1831 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES of NO
13: A. AGE ~~ 13.B. DATE OF BIRTH n~ /11 AA71
MONTH DAY YEAR
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 1 nn"~8663
D, SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. New York:...
(STATE) .
C. CHECK ONE 0 CITY [JI'TOWN
AND PouahkeeDBi
SPECIFY e
D. STREET ADDRESS P. O. Box 1831
B. DI.Itches8
(COUNTY)
o VILLAGE
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
3. A. AGE "5l 3B. DATE OF BIRTH 12 / D9 / ,1966
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Travel Agent
B. TYPE OF INDUSTRY OR BUSINESS Self Employed
15. PLACE OF BIRTH ~'rJJ'~r Vork
16. FATHER
A. NAME Mladen SUcich
B. COUNTRY OF BIRTH V~avI.
17. MOTHER
A. MAIDEN NAME ~A~ ~
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
w
!;(
....
rn
4. EMPLOYMENT
A. USUAL OCCUPATION Deoulv Sheriff
B. TYPE OF INDUSTRY OR BUSINESS DutchesS COUntY
5. PLACE OF BIRTH Anchoreae. AlaskII
(CITY, STATEJC01fNTRY IF NOT USA)
6. FATHER
A. NAME Alfred P. .lava
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME CMherIne MAr~ret SAcldAf
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
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID,LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 21 / 1"
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
0312111.. ~I NMN VtII'Ic
MONTH DAY
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
1ST
2ND
3RD
4TH
at the information
o rY'
o 0
o 0
o 0
I impediment exists
o
o
o
o
my knowledge an
w
en
z
w
o
:::i
1ST
2ND
3RD
4TH
I, being duly swom, depose and
as to my right to enter int9: I~~ ~
21. SIGNATUREOFGROOM~ :.
23. SUBSCRIBED AND SWORN TO BE~ORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York bride and groom named above by any person authorized by Ne.w York Domestic
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pur ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona
TIME MONTH
SEAL SIGNATURE. ~
MAI:if~r~R Falls NY 12590 AM 08
'-..-' STREET 1 flOWN STATE P 03:02PM
~~~R~~RT~~~ IJO~~~N~EE~ 26. SOLEMNIZA I OCCURR 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. 1 ~VIL
DATE AND AT THE TIME AND ~
PLACE INDICATED, C)
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY juttieJ f
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY /#AH>UJ6tlf ../'AtJ.J
SIGNATURE.
MAILl21DRES
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) ~ ~
SIGNATURE. I /
~~~~
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