052
I-
Z
W
en
w
III
o
...J
::>
o
:I:
en
z
o
i=
<
a:
I-
en
Ci
w
a:
w
Cl
<
a:
a:
<
::;
u.
o
W
I-
<
u
ii:
i=
a:
w
u
w
a:
w
:I:
~
en
en
w
a:
o
o
<
~
(3
W
D.
en
a:
w
III
:;
::>
z
o
z
<
tii
w
a:
,...'
en
~:i:z
~~g W
~~t;j ~
I- W Z .....
3dai 0
~~~ u:
z-
~~~ i=
it ;; en a:W
01->-
w~(!; 0
....aJLn
~g;;
COUNTY Dub:bW!
CITYITOWN \Napping<<
DISTRIC"C' 1368
NUMBER
". ~5~~J~R 52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ro.~. Kl8pr~flJRoRNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~ M. RemmENTSURNAME
-1
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
D.
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE. C. SURNAME AFTER MARRIAGE ......,...-..
(OPTIONAL - SEE REVERSE) (OPTIONAL. SEE REVERSE' .. r-vgl
D. SOGIALSEGURITYNUMBER 1Q6.-72--4B31, D. SOGIALSEGURITYNUMBER Q80w5lJ...61~
2. RESIDENCE A. FbTATE) B. ~) 8each 12. RESIDENCE A. AfSTATE) B. ~m Besch
C. ~5CK ONE IijI' CITY 0 TOWN 0 VILLAGE C. ~5CK ONE ~CITY 0 TOWN 0 VILLAGE
SPECIFY West Palm Beech SPECIFY Vl-Jest Palm Beach
D. STREET ADDRESS 4530 POltotlno Way #302 ZIP 33408 D. STREET ADDRESS 4530 P.ortotlno '"Jay #302 ZIP 33-409
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~VES 0 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 28 3B. DATE OF BIRTH MOQ~ / Zl / W6 13. A. AGE 29 13.B. DATE OF BIRTH Mi04 / U. 191~
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Chef A. USUAL OCCUPATION PfDperty M8R11gement
B. TYPE OF INDUSTRY OR BUSINESS WoocIIlld CouRtly ClUD B. TYPE OF INDUSTRY OR BUSINESS ,~.F\ Mgl Ce.
5. PLACE OF BIRTH ~a~~g.d 15. PLACE OF BIRTH ~FbI_~Fk
6. FATHER 16. FATHER
A. NAME Ronald W. K1aprath Sr. A. NAME JOhR Michael RegaR
B. COUNTRY'OF BIRTH USA B. COUNTRY OF BIRTH U S ,A.
7. MOTHER 17. MOTHER
A. MAIDEN NAME UAda Ileady
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Cathy Olen Merrlng
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
o
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
YEAR
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
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALiVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
o
:::l
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, t at tD the best of my knowledge and belief that the informatiDn I prDvided is true and that I declare that nD legal impediment exists
as to my right to enter into the marria state. _~'
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE. ~-
l) USE CURRENT E
23. ~::,;~~~~DC:N1o~~~: ci~Bg~::~E DATE
This license authorizes the marriage in New York S e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perfDrm marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
DATE Q6I07J2Q04
AM
11:53pM 08
08
10 CIVIL
08 08 2004
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'J)~!,\
ZIP
, AT
27. TYPE OF CEREMONY
o ~RELlGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY ns.h ~11
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
;{oot.f
29. OFFICIANT
NAME (PRINT)
TITLE I..~d.
DATE (pI it! (oJ r
AI 1?-5'"90
STATE ZIP
31. WITNESS TO CEREMONY
,
SIGNATURE.
MAILING ADDRESS
I .. t!!.
STREET
30. WITNESS TO CEREMONY
:sLA,.I ~I
:::::::; ~~;~
DOH-9B (11198)
NAME (PRINT)
SIGNATURE.