022
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~ ~R~URNAME
]
COUNTY Dutd\IlS
(;TY/TOWN ~
~~~~1G~ 1388
~~~~J~R 22
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23 SUBSCRIBED AND SWORN EFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State of he bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New ork 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
A FULL NAME
FIRST
Q.
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 122-28-5762
2 RESIDENCE A New York B, n..l~
(STATE) (CorINTY)
C CHECK ONE 0 CITY 0 TOWN ~ILLAGE
~~~CIFY ~..pngP-nl F'"
D. STREET ADDRESS 23 MIl street. 2
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE OJ 38. DATE OF BIRTH
ZIP 12590
D"ES 0 NO
MON
4 EMPLOYMENT
A. USUAL OCCUPATION Relil'Rd
8. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH (~OTtltrt York
6. FATHER
I- A. NAME .Inhn U Knmnmi~
:;;( B. COUNTRY OF BIRTH USA
c 7. MOTHER
tt A. MAIDEN NAME MargINt ..."'"
<( B, COUNTRY OF BIRTH --U 8 A
8 NUMBER OF THIS MARRIAGE 2
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
8. HOW DID LAST MARRIAGE END? (3) D~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? rfI/ i'2A / 04G7A
MONTH DAr Y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 -=S 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
1ST aTQIlI1978 ~., Ne\.., York
2ND
3RD
21.
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I CE~ FY THAT I SOLEMNIZED
THE:"MARRIAGE OF THE PER-
SONS NAME\D" ABOVE ON THE
DA.TE AND AT TijE TIME AND
PLACE INDIC4TE.r1. .., "
... , '.' ...;,...."::.:....~.':~,-.
29. OFFIC'iAtlr ~ . ;: l''';:' I. '-, --.,:
NAME (PR1N"J. I... . .' I i.' _. --....,-~
.'''' ._~fJt;::~
SIGNATURE . . .!,~h I.~
MAILlNG'ADDRESS -
C~.
--_.
TITLE
._._..",...~-
o
o
o
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
If,) J.ttitftJ
frCf ~~11/
L D SUPPLEMENTAL FILE
FROM THE BRIDE
M~ P ~RENT SURNAME
~
11. A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~'1111-.
C. SURNAME AFTER MARRIAGE f(anYvniIr
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER ~!i4!i4
12 RESIDENCE A ....... ynrtr B nulr-t-a
-(SfflE) . -.-remmr----
C CHECK ONE 0 CITY 0 TOWN 0 llIf\LLAGE
~~~CIFY ~
D, STREET ADDRESS ....23.-MII atNM. 2 ZIP 125GO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D"ES 0 NO
13. A. AGE 53 13.8. DATE OF BIRTH MOQ;i / QJ /'~1
14. EMPLOYMENT
A USUAL OCCUPATION RetPI
8. TYPE OF INDUSTRY OR BUSINESS BudInton Colt FfIdoIy
15. PLACE OF BIRTH (~TYSP
16. FATHER
A. NAME Jabn MIm>iJ1If8IH
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME I..uGy C8mpl:ailll
B. COUNTRY OF BIRTH U 8 A
18 NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
8. HOW DID LAST MARRIAGE END? (3) 0 ~ORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? QI/' i'2A / ~
MONTH DA'" ---
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S IZJ 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
1ST O8I2&I2OO2~$.NewYOfk
2ND
3RD
0....
o
o
04105I2OO4
by New York Domestic
DATE
TIME
MONTH
YEAR
YEAR
ZIP
04
08
04 2004
PM
o 0 RELIGIOUS
o OTHER, SPECIFY
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.
DOH-98 (11/98)
/I/€VE,e
o CITY OF CJ TOWN OF 0 VILLAGE OF
SPECIFY
zw..
31. WITNESS TO CEREMONY
.------
NAME :PRINT)
SIGNATURE.
I.t 5 C 1:> 1'..1- .8.L!.iI.Je