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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Elb<bL~onajd K'i~iENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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
I
COUNTY DJ ttcl)~'S
CITYfTOWN Wappif'lger
~~~~kc~ 1 '368
~5~~J~R 84
1. A FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SDCIAL SECURITY NUMBER 098..s?4218
2. RESIDENCE A. N ('1rATE) B. q~ess
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
AND W .
SPECIFY Appln~r
o STREET ADDRESS 32 Smith Crossing ROAd ZIP 1?5qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES it! NO
3 A AGE 41 3B. DATE OF BIRTH M~ / Q~ /1il?3
4. EMPLOYMENT
A. USUAL OCCUPATION RAilrnAd Cnndll~tnr
8. TYPE OF INDUSTRY OR BUSINESS M~rn- Nnrth
5. PLACE OF BIRTH ~~~~!~.1;t ';( NOT USA)
6. FATHER
A NAME Fdws:lrd ChArletnn KlJs~
8. COUNTRY OF BIRTH lJ ~ A
7. MOTHER
A MAIDEN NAME Joan Annette Colaiante
8. COUNTRY OF BIRTH I I S A
B. 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
II:
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21. SIGNATURE OF GROOM ~
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{ SEAL }
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NAME (PRINT)
SIGNATU~
MAkiNG ADDRESS
LO Middlebush
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
n
CI
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
3:CX)~ g '1 'c~
STATE
27. TY5DF CEREMONY
o [J"'RELlGIOUS
9 0 OTHER, SPECIFY
1 0 CIVIL
~.,j'i7:~:m :rJ! D mAs _ ~. $.,AN ~: ,m 2. c · f r : e s+
SIGNATURE ~ ~J~a,,-e... ~ DATE ~, '1. :J.tJt)f,t"
MAILING ADDRESS , ~ -9
/',., P. YJ\Q,'r'\ Sf. ,ShrlAbt14:1!. N'I ''''$'81'
STREET CITYfTOIlfN ' STAtE ZIP
30. WITNESS TO CEREMONY . I 31. WITNESS TO CEREMONY \ J
N NAME (PRINT) fYl a. r k C. Vo.. n
SIGNATURE ~ ~ f2 v::::..- A
~ I A I t: ~ILt: NUM~t:H
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Margi~fflt Mary Mcg~~fsURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C S~~~~~N~~~~~t~~e~~sJ;Zuss
o SOCIAL SECURITY NUMBER 332~7 4.. 7100
12 RESIDENCE A. N ';(TATE) B. D~li
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W. .
SPECIFY aprm~r
o STREET ADDRESS~? Rmith ~rnc:.c;.in!J Ro::trt ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M~QH . /11,\y (9~:~
13. A. AGE 32
14. EMPLOYMENT
A. USUAL OCCUPATION Teac~e-r
8. TYPE OF INDUSTRY OR BUSINESS H Hlldson Seh Dist
15. PLACE OF BIRTH ycm~RRJi~~uUl;noi5
16. FATHER
A. NAME IQhn Fr~nNc;. Me ~lIirp
8. COUNTRY OF BIRTH I I S A
17. MOTHER
13.8. DATE OF BIRTH
A. MAIDEN NAME Mary Joan Shevlbr-idge
B. COUNTRY OF BIRTHU S 4.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
8. 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 {] 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
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
,
071230004
DATE
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
DATE 07f2312OO4
AM
02:57 PM 07
24
2004 09
21 2004
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY (J)l4..T ....
~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J TOWN OF 0 VILLAGE OF
SPECIFY <::-) h ru.-b Oa.J..-,
Dyte