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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~EJosepb SclrdEWsURNAME
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 urpDse of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY nl rtt'.n~tl;
CITYrrowN Wapflif'\ger
~~~~cFi 1368
~5~~J~R 83
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER Q94. 7 4.9081
2. RESIDENCE A. N :tATE) B. ~FSS
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY 9pp1n~r
D. STREET ADDRESS 83 De Germo HiII~ R09d ZIp. 1?~go
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 'll NO
3. A. AGE 26 3B. DATE OF BIRTH M~ / ~1v / 1il7
4. EMPLOYMENT
A. USUAL OCCUPATION Currier
B. TYPE OF INDUSTRY OR BUSINESS Oynama'lf
5. PLACE OF BIRTIH ~~J~~~~ Vnrk
6. FATHER .
A. NAME Anthnnv \/inr.Ant ~nn
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Colleen SUSaR La LouRa
B. COUNTRY OF BIRTH II S A
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
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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
o
o
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{ } NAME (PRINT)
SEAL SIGNATURE ~
M~lt:oIG APDR SS
'-v-' LU MI e
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE. ·
nnu no Ii ..InO,
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ra~AARe Sq~M;;~NT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Q8\'-iRQ
(OPTIONAL. SEE REVERS~ .
O. SOCIAL SECURITY NUMBER 2n-So..5154
12. RESIDENCE A. N ~TATE) B. O~
C. CHECK ONE 0 CITY IijI' TOWN 0 VILLAGE
AND \Ai .
SPECIFY vv4i'ppnger
D. STREET ADDRESS 83 De Garmo Hills Road
E.
ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES i!I NO
~H . -"2~AY 19~
13. A. AGE 2A1
14. EMPLOYMENT
A. USUAL OCCUPATION ClImer
B. TYPE OF INDUSTRY OR BUSINESS Dynamax
15. PLACE OF BIRTH ~~EI~Y IF NOT USA)
16. FATHER
13.B. DATE OF BIRTH
A. NAME Brian Keith Sq'litf'
B. COUNTRY OF BIRTHII S A
17. MOTHER
A. MAIDEN NAME ~.nR. C. Roy
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
0,
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOLlSE(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
o 0
o 0
o 0
o 0
impediment exists
,
TIME
MONTH
DAY
YEAR
MONTH
YEAR
ZIP
AM
02:54 PM 07
22
200409
19 2004
1~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY cto" t:. ~~
(CHECK ONE AND SPECIFY)
'fl. CITY OF 0 TOWN OF [j VILLAGE OF
SPECIFY 'S I[IIkL hUT.