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COUNTY Dutoh~..
CITYfTO~J \Napp~
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~pY 0 HLI9!IINT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
JIHlGa L AA8tdENT SURNAME
-1
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME.AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 057 ~ 4.2575
2. RESIDENCEA.~)Yodc B. ~~_
C. CHECK ONE [ill' CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Rear.nn
D. STREET ADDRESS 1~ OuAl'look Avenue ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? []fvEs 0 NO
MO~ / g~ / y1882
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hu.........
(OPTIONAL. SEE REVERSE) 11""'"
D. SOCIAL SECURITY NUMBER ~ 70-7760
12. RESIDENCEA. NIWEysFk B. ~
C. X~6CK ONE. q".CITY 0 TOWN 0 VILLAGE
SPECIFY Beacon
D. STREET ADDRESS 130 OVeJIook .4\veR". ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAG~? !:4'YES 0 NO
13. A. AGE 20 13.B. DATE OF BIRTH McIJB / 21 ~9113
14. EMPLOYMENT
A. USUAL OCCUPATION CBBIi.
B. TYPE OF INDUSTRY OR BUSINESS FOIM & '.tJesh Mebll
15. PLACE OF BIRTH ~r~IJNel.v YGFk
16. FATHER
A. NAME Jalleph .A.RBt8It
B. COUNlTRY OF BIRTH U & A
17. MOTHER
A. MAIDEN NAME Petri. Reera
B. COUNTRY OF BIRTH U S ^
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3. A. AGE 22
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION Sales Associate
B. TYPE OF INDUSTRY OR BUSINESS PItco .
5. PLACEOFBIRTH~~York
6. FATHER
A. NAME ~ir.:tuIP-I i: WI~
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME SUslR P. Van Norstrancl
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o
(2) 0 DEATH
DEATH
DEATH
o
(2) 0 DEATH
0' 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. 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
o 1ST
o 2ND
o 3RD
o 4TH
e ief that the Information I provided is true an
o
o
o
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that to
as to my right to enter into the marriage sta
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. SIGNATURE OF BRIDE ~
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DATE
of the bride and groom named above by any person authorized by New
w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second Dr subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
York Domestic
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{ SEAL }
'-.-'
TIME
MONTH DAY
YEAR MONTH
YEAR
07
17
09
14 2004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(C1CK ONE AND SPECIFY)
fi/ CITY OF TOWN OF 0 VILLAGE OF
.
SPECIFY