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COUNTY 0ut0hM!;
CITYITOW/W \Napp~
~~J~~c;;r 1388
~Q~~J~R 5$
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jean ("..hristiAQ Ma,.hpll
MIDDLE CURRENT SURNAME
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
HP.lp-n I ~
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE M.lSbIIIl
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 549-43-3684
12, RESIDENCEA. ~lork B.~
C. CHECK ONE 0 CITY D"ftOWN 0 VILLAGE
AND ,.,_ .
SPECIFY VVMJ1PT'"
D. STREET ADDRESS 2 EdgeIlJ~1 Drtve ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE "8 13.B. DATE OF BIRTH ~ / ..,A
It: MCM1'I'I "iiA'I'
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Hudson Haven Car. Ctr.
15. PLACE OF BIRTH ~~II
16. FATHER
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 570.51-2793
2. RESIDENCE A. I ~I B. ~ SIR Cou~
c. CHECK ONE lJII' CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Self I SlkP-
D. STREET ADDRESS 2688 Filmore street ZIP 84106
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r:YvES 0 NO
MoA1 /.w / v1Q18
1~590
YES c:Y NO
/1~1i
3. A. AGE 2fi
4. EMPLOYMENT
3B. DATE OF BIRTH
l-
S;
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c
5LL
-ILL
<C
A. USUAL OCCUPATION Pilat
B. TYPE OF INDUSTRY OR BUSINESS Skr'J:! st Airlines
5. PLACE OF BIRTH~~II
6. FATHER
A. NAME Roger Mamhall
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIOEN NAME Cheryl MensbrJeIge
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Donllld Sasse
B. COUNTRY OF BIRTH 1I S A
17. MOTHER
A. MAIDEN NAME Carol aorcltn
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
o
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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DA V 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 VEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly swom, depose and sa)'
as to my right to enter into the m
o
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o 0
o 0
o 0
o 0
h t no legal impediment exists
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23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR CLERK~ DATE 06I14l2OO4
This license authorizes the marriage in New York Sta bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
,-A-,
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
MONTH
TIME
AM
M
15
08
13 2004
08
ZIP
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ])u;h.~<iS.5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY?" v....j h~, e...Y' ~ T f!.
~~~ W
f-;itf- ?-
M! ~ ~ 29. OFFICIANT
f- W Z c( NAME (PRINT)
~d~ 0
~ ~ ~ i! SIGNATURE
Z 5 I- MAILING ADDR
~gJl'; -
itoen a:
Of->- W
w~~ 0
b~'"
z :; ~ NAME (PRINT)
SIGNATURE ~
DOH.9B (llI9B)