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STATE Of NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
23. SUBSCRIBED AND SWORN
SIGNATURE OF TOWN OR CITY
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY
CITYfTOWN
DISfRlCT
NUMBER
REGISTER
NUMBER
0...__
\Afapptnger
..
1388
44
1. A. FULL NAME
MIDDLE Frank J. ~~URNAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY ~AJappinger
(:) D. STREET ADDRESS 32 Kendell ~ ZIP
m E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO'"
N L _L
.. 3. A. AGE 24 3B. DATE OF BIRTH MONTH D6 DAY Z2 YEAR 1
12&-72-4822
(STANew YaFk B. (cou~ess
o CITY 0 TO~ 0 VILLAGE
4. EMPLOYMENT
A. USUAL OCCUPATION 8Bles ..seste
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH
Unens & TNngs
(CITY, .PAI.,....) Ne\.... YOFk
6. FATHER
A. NAME Keith V'J. PaFker
B. COUNTRY;OF BIRTH USA
7. MOTHER '.
A. MAIDEN NAME SUe Ann Ceront
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
o
B. HOW DID LAST MARRIAGE END? (3).0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
o
21. SIGNATURE OF G
~
{ SEAL }
'-.-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~be~ FefDfmfc.AME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
rwker
078 66 3222
12. RESIDENCE A. ~.. Va'&' B 0uI--_
(ST~" I .... . (COU~.""-
C. CHECK ONE 0 CI'TY 0 TO"'l/lI' 0 VILLAGE
AND
SPECIFY ~ppinger
D. STREET ADDRESS 32 Kendell DrIve
12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO'"
A AGE --- 13.B. DATE OF BIRTH _.I' 1.-/ "98
. &.iC. MONTH In DAY 2 YEA" .
ZIP
DEATH
14. EMPLOYMENT
A. USUAL OCCUPATION 8Bles PefBBR
B. TYPE OF INDUSTRY OR BUSINESS RIVe GIFI
15. PLACE OF BIRTH (crrv, Ik'.nNNT'tNk
16. FATHER
A. NAME NiehBl. Manuel FeFMndez
B. COUNTRY OF BIRTH U S ,\
17. MOTHER
A. MAIDEN NAME Aida Irma Torres
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
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
YEAR
o
o
o
by New York
TIME
MONTH
YEAR
MONTH
YEAR
ATE
o(f
05 21 07 192004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY M ltrfS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
':szJ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY YDu.ghJUiP ~
27. TYPE OF CEREMONY
o Ji. RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
TITLE
r?
(t?...{~r
511.'1 1~1f
STATE