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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thor R Mi~i
MIDDLE cJ.G;ENT SURNAME
::I
COUNTY ~
clryrrowN Wappl"fllM
~~J~~1r 1~A
~~~~J~R 28
1. A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~5542
2. RESIDENCE A. ~) Vnrf( B. ~eslil
C. CHECK ONE 0 CITY D.l'rOWN 0 VILlAGE
~~gcIFY FiKhlril1
D. STREET ADDRESS is LAm~lg/"f QrAet
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE]6 38. DATE OF BIRTH
4. EMPLOYMENT
ZIP 12508
o YES EYNO
A. USUAL OCCUPATION i:l~il
B. TYPE OF INDUSTRY OR BUSINESS Wreless Communication
5. PLACE OF BIRTH
6. FATHER
A. NAME RobeJt BidI:isteIli
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME AnA SGelAdA8FG
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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B. HOW DID LAST MARRIAGE END? (3) CAIIl,VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 01/ DA~7 / ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? DllI'Es 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
01/17.Q003 Poughkeepsie, New York 0 oW'
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{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~1iI L BRgENTSURNAME
.-J
11. A. FULL NAME
FIRST
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT be\,-Jis
C. S~S~~(M~~~t~~Cg~SE) Mikelic:
D. SOCIAL SECURITY NUMBER 5~37
12. RESIDENCEA. ~~onc B. Q~s
C. CHECK ONE 0 CITY 0 tjIOWN 0 VILLAGE
~gclFY Fisbkill
D. STREET ADDRESS 16 Lamplight street ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE~--YES o.,;NO
13. A. AGE 36 13.B. DATE OF BIRTH Mo3M / 3~ ~$lfi7
14. EMPLOYMENT
A. USUAL OCCUPATION Nalary Public:
B. TYPE OF INDUSTRY OR BUSINESS Mortgage
15. PLACE OF BIRTH f~IIMl~'J(gml,
16. FATHER
A. NAME H8n:y lee la-Jig
B. COUNTRY OF BIRTH U S ,6.
17. MOTHER
A. MAIDEN NAME Kathleen /ld;JdnIy V.'allls
B. COUNTRY OF BIRTH England
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 Q
B. HOW DID LAST MARRIAGE END? (3) 0 ~ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ^.,./ ..!:l4 / ~
MONTH....... OM I ..--.
D. ARE ANY FORMER SPOUSE(S) ALIVE? DIllIES 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
931a1J2004 PouGhkeep5le, ....... York 0 OW'
o 0
o 0
DATE
person authorized by New York Domestic
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
YEAR
MONTH
YEAR MONTH
ZI
l~IL
AM
M 04 18 06 14 2004
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUNTY ~I/I'Z'"
C.
.
NAME (PRINT)
SIGNATURE ~