031
STATE OF NEW YORK r- STATE FILE NUMBER I
::I COUNTY ~ (THIS SPACE FOR STA TE USE ONL Y)
CITYITOWN W.ppI~ DEPARTMENT OF HEALTH
~IT.:fii ; AAA AFFIDAVIT, LICENSE and
, ~~~~R 31 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. fill NAME M~M lan~ENT SURNAME 11. A. FUll NAME BBWIY E. UI~SURNAME
FIRST FIRST
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B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ch.v
C. S~S~J~~~~~eg~SE) UlRROR
D. SOCIAL SECURITY NUMBER 1-44 74-1251
12. RESIDENCE A. ~r.k: B. ~_B
C. CHECK ONE 0 CITY DoIOWN 0 VILLAGE
AND 'A.....
SPECIFY v_ppnger
D. STREET ADDRESS 33 st Nicholas Road ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES o.;No
13. A. AGE 39 13.B. DATE OF BIRTH ~ / (l4 ~~
14. EMPLOYMENT
A. USUAL OCCUPATION Dam88tic liRgiReer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~N.J.frsey
16. FATHER
A. NAME RabeR Len..-
B. COUNTRY OF BIRTH U 8 A
17. MOTHER
A. MAIDEN NAME Virginia Iletrlck
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C. SURNAUE AFTER MARRIAGE
(OPTIONAl. . SEE REVERSE)
D. SOCIAL SECURITY NUMBER 209-56-8694
2. RESIDENCEA.~)Yodc B. ~all
c. CHECK ONE 0 CITY Olil'I'OWN 0 VILLAGE
AND Wa'
SPECIFY pprvm
D. STREET ADDRESS 33 at Nicholas Road
E. IS RESlOENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 30 3B. DATE OF BIRTH
4. EMPLOYMENT
ZIP 12590
o YES ~NO
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A. USUAL OCCUPATION \N8n:aRty M8R&ger
B. TYPE OF INDUSTRY OR BUSINESS HlRO Motors SlIII USA
5. PLACEOFBIRTH ~...
6. FATHER
A. NAME Bem8rd Jc.eph ....RROR
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lyn Marie JehaMen
B. COUNTRY OF BIRTH U &; A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DE.ATH
DE.ATH
100
B. HOW DID lAST MARRIAGE END? (3) DieIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 11/ oA.;I3 / ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1 0 0
B. HOW DID lAST MARRIAGE END? (3) 0 """ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? I\A / !is / ~
MONTH ....... OA" lfII!MW""I'
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YE.AR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1111312002 Clift.". New Jersey
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0'; 1ST G4I1612OO4 Salem, Ne';; JerMy 0.; 0
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
be lef that t e in ormation I provided is true an t at eclare that no legal 1m Imen! exists
22. SIGNATURE OF BRIDE ~ ..Bl.1 r. L O~. .1 j ~")/..)
U CURRENT AME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St e of the ride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew 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 subs uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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YEAR
NAME (PRINT)
SIGNATURE ~ -
MAILING ADDRESS
TIME
MONTH
YEAR
MONTH
04 20 06 182004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY Of R"TOWN OF 0 VILLAGE OF
SPECIFYt~_f>fl ~P- r
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 27. TYPE OF CEREMONY
TIM M. DAY YEA 0 0 RELIGIOUS
'I 9 0 OTHER, SPECIFY
~CIVIL
29. OFACIANT
NAME (PRINT)