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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Inhn A Aaunrinn
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN T B RE ME
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York S te of the bride and groom named above by any persDn authorized
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used Dnly fDr the purpose of a second or subse uent ceremony.
24. TOWN .OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) Gloria J Mome
COUNTY outm--
CITYfTOWN W~ngIM
~~J~fFT 1 ~
~5~I~J~R 78
1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
O. SOCIAL SECURITY NUMBER ~nR..dRnR
2. RESIDENCE A. ~Pr 'ldand B. ~
C. CHECK ONE 0 CITY []hOWN 0 VILLAGE
AND 0_. .....Aft
SPECIFY ~m. Y-"
O. STREET ADDRESS '27 Middle H~ ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 25 3B. DATE OF BIRTH MJl? / :.~
n?AM
YES rJI NO
/ Y'UP9
4. EMPLOYMENT
A. USUAL OCCUPATION Di~nr Of ErNimnmental RP.rvil'!P.!R.
B. TYPE OF INDUSTRY OR BUSINESS janitorial s,rvtM
5. PLACE OF BIRTH &Jtvuoo.I'.LI. u.u.u
~~SA)
6. FATHER
A. NAME RodaIfn TAnhnrr.in AAunr.inn .Ir
B. COUNTRY ~F BIRTH USA
7. MOTHER
A. MAIDEN NAME Joj Lvnn LlttAc
B. COUNTRY OF BIRTH II 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
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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 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
o
21. SIGNATURE OF GROOM ~
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{ SEAL}
'-v-'
SIGNATURE ~
MAILING ADpRESS
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jyt~ M P~~BENT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Asuncion
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 Z7 .s;n.~
12. RESIOENCEA. ~EYork B.~
C. CHECK ONE 0 CITY [)jItOWN 0 VILLAGE
ANO .
SPECIFY POI'St'kAP.paP-
D. STREET ADDRESS 38 RAnr RMtI
13. A. AGE 28
ZIP 1~
YES iY NO
/.isms
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
I\tt . /1'>
MClRTA flln'
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Ral~
B. TYPE OF INDUSTRY OR BUSINESS Morning St.r Bot*' Store
15. PLACE OF BIRTH .~~York
16. FATHER
A. NAME .1nIIP.ph S;...nr.iR Pmaf"C'
B. COUNTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME Hllen Ruth Mead
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
0' 0 0
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o
o
o
o
ent exists
22. SIGNATURE OF BRIDE
DATE n7/1?nnn4
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZI
09:cxf'M
PM
07
13
09
10 2004
C.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
A E
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Dut"che~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~:O()
~AS:~~~~~T Rev, Ed w a.. r iJ ,q....J" f) e S TITLE
SIGNATURE ~ .&.I,1K~/ld tJ. O-<rneJ./ DATE
MAIL2: ADDRESS ~
:J;;REEf Sftlc.Kenft!; (/ ;;-:fTOW~ ~hK '('~ps Ie
30. WITNESS TO CEREM NY f t f() l
NAME (PRINT) m e.~1 'l- 0 fJ
SIGNATURE ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1;l(TOWN OF 0' VILLAGE OF
SPECIFY P" V:j h K... e e psi e..
'PAs+ar
7- c7-~ - o~
1J y 1~~~..:3
STATE ZIP
31. WITNESS TO CEREMONY
..:To 'Ice
NAME (PRINT)
SIGNATURE~