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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RabeIt B. Larenm
COUNTY Duldu 51
CITY/TOWN ~
DISTRICT .1
NUI~BER
. REGISTER 89
NUMBER
A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 130-58-1322
D SOCIAL SECURITY NUMBER
2. RESIDENCE A New York B. Dutche8a
(STATE) ~ (COUNTY)
C CHECK ONE _ I:J CITY TOWN 0 VILLAGE
~~~CIFY I:..r Fi
D STREET ADDRESS 1Z4 &ouIh HghlanG ROIG liP 12580
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ct NO
10 / 28 / 1
3 A, AGE 31
38. DATE OF BIRTH
YEAR
MONTH
DAY
4. EMPLOYMENT
A USUAL OCCUPATION Conl:r1iIctar
5. :LA:Y::::I:~USNOrth~;m~=ork
(CITY, STATE/COUNTRY IF NOT USA)
6, FATHER
A, NAME Benjamin Lorenzo
B, COUNTRY OF BIRTH PuertO Rico
7. MOTHER
A. MAIDEN NAME BrendI Moore
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
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
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
I STATE FILE NUMBER
I (THIS SPACE FOR STATE USE ONL Y)
tJltbdd
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I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Christine L Southard
~
11 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Lorenzo
(OPTIONAL. SEE REVERSE) Q95.68.1722
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A New York 8 DutcheII8
(STATE) J (COUNTY)
C, CHECK ONE CLCIIY. !J'9'j'OWN 0 VILLAGE
~~~CIFY E8Bt I-IShICIII
1Z4 &oua\ tIgN8nCI ROIG
13. A. AGE 28
13.8. DATE OF BIRTH
MONTH
DAY
YEAR
14, EMPLOYMENT
A, USUAL OCCUPATION Teacher
8. TYPE OF INDUSTRY OR BUSINESS HelTlCIS U. F. S. D.
15. PLACE OF BIRTH ace.nsIde. New' York
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A. NAME Robert Edmond Southard
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME P8trIda MeznIo
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
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (31 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
15T 0 0 15T 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 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 sta , . .)ffi 1./. 17
<~t;/j4(Cri/-rYL~~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ l/
USE 9JARENT NAME
DATE 08t20I2004
F.... NY 12590
CITYfTOWN STATE
URRED 27. TYPE OF CEREMONY
DAY YEAR 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
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TITLE
DATE
('
STREET
30. WITNESS TO CEREMONY
CITY/TOWN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
by New York Domestic
TIME
YEAR
MONTH
ZIP
AM
01:12>M
08
28, PLACE WHERE MARRIAGE OCCURRED
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
SPECIFY
STATE
liP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~