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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
n~~ M CesC!r~E"'SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Imf}' L TUGl@f;RENT SURNAME
.-J
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT,
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A.
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~JN~~~~:~~e~~SE)Cesar
D. SOCIAL SECURITY NUMBER CJ65.-7g...8157
12. RESIDENCE A. NfMlor:k B. ~
C. CHECK ONE 0 CITY 0 TOWN ~ILLAGE
AND \Al. HI
SPECIFY ,vwapplAgelll F 18
0, STREET ADDRESS 9 North Gilmore BoLlI~rd ZIP 12G90
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~YES 0 NO
13, A. AGE 34 13.B. DATE OF BIRTH MSJi / JO. ~9G9
14. EMPLOYMENT
A. USUAL OCCUPATION student
B, TYPE OF INDUSTRY OR BUSINESS \f/est. Comm. College
15. PLACE OF BIRTH ~,""~~.
16. FATHER
109-70.9347
~MfE~ork B. ~es.
C. CHECK ONE 0 CITY 0 TOWN [il'VILLAGE
AND
SPECIFY ~ppin~ FAI."
D. STREET ADDRESS Q N ~llmor. ~IAVArd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cVvES 0 NO
MO~ / 51 / y1i71
3. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION C',tHTP-f!tion Officer
B. TYPE OF INDUSTRY OR BUSINESS state Of N Y
5. PLACE OF BIRTH ~~~~uXprk
6. FATHER
A. NAME ~P-nI"gP-K U l'..P-!liLSlr
B. COUNTRY OF BIRTH H8ItI
7. MOTHER
3B. DATE OF BIRTH
A. NAME James I!m.-JBm Tucker
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jf!JlIf!Ie Devonshire
B. COUNTRY OF BIRTH U S 1'.
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME Sonia o.eRCIOl
B. COUNTRY 'OF BIRTH Haiti
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
000
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
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
(2) 0 DEATH
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
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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri
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o 1ST
o 2ND
o 3RD
4TH
lief that the information I provided is true
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBEO ANa SWORN T BEFORE
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the <<1arriage in New York St
Relations Law ~11 to perform marriage ceremonies withi
o If checked, this license is
24. TOWN OR CITY CLERK
YEAR MONTH
YEAR
DATE
of the ride and groom named above by any person authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o be used only for the purpose of a second Dr subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
~
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
DATE DSf..23J2004
AM
PM
06
24
08 22 2004
AT ZIP
27. TYPE OF CEREMONY
O;!( RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
OATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY tb7"c.K4"~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF j( VILLAGE OF
SPECIFY MARhA/6A".If~ M.-<:5
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) J'l\\ (h,~. rro tU2.\ <:>
SIGNATURE~ ~ \~... ~~ J\~