056
Q.
N
I-
Z
w
m
w
'"
o
-'
::l
o
:r
m
z
o
~
cr
ti;
i3
w
cr
w
Cl
<
[[
cr
<
::0
u.
o
W
I-
<
()
iL
>=
cr
w
()
w
cr
w
:r
;:
m
m
w
cr
o
o
<
>-
u.
C3
W
Q.
m
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~ct:aer:
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~5&-04fl?
12. RESIDENCEA. ~Yodc B. I:?A~F'I
C. CHECK ONE 0 CITY [ljI'rOWN 0 VILLAGE
AND lA&.. .
SPECIFY vRlppmgel"
D. STREET ADDRESS 21 OSllITey line ZIP 1259f'l
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES l3I" NO
13. A. AGE 29 13.B. DATE OF BIRTH M~ / 11 ~~fj
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Mlnpower Temp. AQenOf
15. PLACE OF BIRTH ~"F't~)
16. FATHER
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
GRER Picber'tJ1!~ SURNAME
COUNTY Dtlt-:f'rrs
CITYrrOWN Wapp",
DISTRICT 1368 .
NUMBER
~5~~~R 56
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q8&.64..1892
2. RESIDENCEA.~;Yodc B. Q~es.
C. CHECK ONE 0 CITY [il'TOWN 0 VILLAGE
AND Wa.
SPECIFY ppnger
D. STREET ADDRESS 21 0 Surrey lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~ / Sf / y1B79
3. A. AGE 25
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Saftware ElVneer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M. .
5. PLACE OF BIRTH _"'~_A~ew York
6. FATHER
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jena~ A Alba_NT SURNAME
~
FIRST
...
:>
<C
c
u:
u.
::E<C
A. NAME Qary Raymond Reiter Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME PetrlGlI Merle Ble.
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
A. NAME Horace Haf.fman Clal=k Albaugh
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME leslie lorraine Flestar
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
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
0:
W
III
::;
::l
Z
o
z
<
...
w
W
0:
li;
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MAI'lRlAGE 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
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
w
en
z
w
o
:i
~
{ SEAL }
'-v-'
z :i
a: 0 W
::l >=
I- ~
W < 29. OFFICIANT
a: N
I- Z NAME (PRINT)
m ::0 0
::l W
::0 -' u:: SIGNATURE ~
0
?- m
z i= MAlLIN
< u.
C3 0 a:
iL
u. m W
0 >-
< 0
w 0
b '"
z ~ NAME (PRINn
SIGNATURE ~ .
n_u II"\n 104 04 Inn\
..
NAME (PRINn
SIGNATURE ~ ..
0,
o
DEATH
o
(2) 0 DEATH
ose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
MONTH DAY
YEAR
MONTH
YEAR
ZIP
09:5~~ 08
15
08
13 2004
CIVIL
28. PLACE WHERE MARRIAGE ocr~RF~ .. _II
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHEC~ AND SPECIFY)
M~ TOWN OF D' VILLAGE OF
PECIFY~IfFC~ ~
'"