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COUNTY
rkJiM.....
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wslvne 1 RamUJ
'MiDDi!' CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
1
{;ITYfTOWN ~PP"""'"
· ~~~~~C~ 1~
~5~~J~R 7!!i
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Pliltrir.iA I I=mmnnK
MIDDLE CURRENT SURNAME
~
1, A, FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ('la Iffy
C. SURNAME AFTER MARRIAGE Bardl J.ljJ
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 117.1O..7QR~
12. RESIDENCE A. ~ATE) B. ~~P-RIl
C. CHECK ONE D CITY D ....OWN D VILLAGE
AND ...~.
SPECIFY v_pp~
D. STREET ADDRESS 1 g FJeldIdona 90ulAVArd
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~ 44 1 !i7n
2. RESIDENCE A. NY B n. Jtr.:hP-Rll
- ~'fA TE) . --reotlI'm)
C. CHECK ONE D CITY MOWN D VILLAGE
~~CIFY Wappin~
D. STREET ADDRESS 1 g Fleld&tone BouIAVArd ZIp. 125SM)
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~NO
3. A. AGE 52 3B. DATE OF BIRTH MO,A9 / D1~ / y195-1
4. EMPLOYMENT
A. USUAL OCCUPATION T~
B. TYPE OF INDUSTRY OR BUSINESS I-ligJlland F8I.. CntrI Sl!h
5. PLACE OF BIRTH ~~cut
. 6. FATHER
A. NAME [)nnpl~ GI RIIIIV 88mIE'
B. COUNTRY OF BIRTH USA
7. MOTHER
ZIP 125M
YES Clt"NO
/1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
13. A. AGE 46 13.B. DATE OF BIRTH MoQ3' / ~
14. EMPLOYMENT
A. USUAL OCCUPATION TP-JIr.:hN
B. TYPE OF INDUSTRY OR BUSINESS HGt'lend CNrI. $d\, o;d;
15. PLACE OF BIRTH ~_~ X.-
16. FATHER
A. NAME Jaseph Fnlncis Dilly
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME call.. la.t.orst
B. COUNTRY OF BIRTH Germeny
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME JeeR FRlACeI JUclloR
B. COUNTRY OF BIRTH I) S A
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3) D ~VORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 08/ na / "XV'II\
MONTH DAY YEAR MONTH OAr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
D D 1ST 08J08I2000 Motltgomely. t.~!Yor.k De; D
D D 2ND D D
D D 3RD D D
D D 4TH D D
knowledge and belief t at t e information I provide I~ and that I declare that no legal impediment exists
IGNATUREOFBRIDE~ ~~ f~
USE CURRENT NAME
DATE 07JnRf.X104
by New York Domestic
o
1,
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, t at.to the best of
as to my right to enter into the marriag state.
I1lJ.-
21. SIGNATURE OF GROOM ~
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE M
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 ork State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked. this license is to be used only for the purpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-..-'
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
10:2lt~
06 2004
07
09
09
IP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRE,D, J
A. STATE NEW YORK B. COUNTYDtJmlIe~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~ TOWN OF O' VILLAGE OF
SPECI,FY U)~$$t;1(
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~