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COUNTY
CITYfTOWN
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REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.,n Keith l1Mm.sJ&
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
nt~"''''~r
WappngeI'
1368
39
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
T_h8 Ren8~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
S. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
S. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
Ill:Inter
45Q..9:J..6602
12. RESIDENCE A. ~w va...... B Da...l-.Ih
(ST~I . .... . (COUa&;njI...... eM
C. ~~5CK ONE 0 CITY 0 TO~ 0 VILLAGE
SPECIFY \H8ppinger
D. STREET ADDRESS 148 revm View DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO .;
~A AGE ~5 13.B. DATE OF BIRTH _L 3/
HI ',&. MONTH 08 DAY 1 YEA~9'71
14. EMPLOYMENT
A. USUAL OCCUPATION '..Vaitr'ess
B. TYPE OF INDUSTRY OR BUSINESS
21]..2],-4446
2. RESIDENCE A. 11.1--- Va.&. B ny.............s
(STATEj- I H\ . (COUNTT) ILtwI\.._
C. CHECK ONE 0 CITY 0 TO. 0 VILLAGE
AND
t") SPECIFY WappiRger
:g D. STREET ADDRESS 148 rOWR \AIW DrIv. ZIP
('Ii E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO';
.... 3 A AGE ry;: 3B. DATE OF BIRTH ...L _L 1
. . _., MONTH 8~ DAY 2B YEAR
4. EMPLOYMENT
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A. USUAL OCCUPATION I!ngineer
B. TYPE OF INDUSTRY OR BUSINESS I. D. M.
5. PLACE OF BIRTH (CITY, _ ~)Maryl8Ad
6. FATHER
A. NAME Brian Keith HYAt8r Senior
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
Otltbeek GteakhotlSe
15. PLACE OF BIRTH (CITY, itMl~~A1ex.
16. FATHER
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A. NAME
TilortlS OIa"d8nd Jr.
B. COUNTRY OF BIRTH USA
17, MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Glsele J. Me ClMry
US,.
1
Patricia Rena, Craton
USA
1
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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B. HOW DlO LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
YEAR
YEAR
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(3) 0 ANNULMENT
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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
o
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
MONTH DAY
D. ARE ANY FpRMER SPOUSE(S) ALIVE? 0 YES 0 NO
('Ii 10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
('Ii 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
that the information I provided IS t
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21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR-CITY CLERK ~
This license authorizes the marriage in New York S e of the bride and groom named above by' any person authorized
Relations Law ~11 to perform 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 urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
Domestic
r-I'-.
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
YEAR
YEAR
TIME
MONTH
E
AM
A
27. TYPE OF CEREMONY
OJ{. RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY~~~S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .a TOWN OF 0 VILLAGE ~~
SPECIFY h//I/~/I/(;.IfR Aiifi!/P
S E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
5 ., ,., ~ 6'1
7/00
NAME (PRINT)
SIGNATURE ~
DOH.98 (11198)
SIGNATURE