021
STATE OF NEW YORK I STATE fiLE NUMISt:H
::I COUNT'i nutehMS (THIS SPACE FOR STATE USE ONL Y)
CITYITOWN \Nappa., DEPARTMENT OF HEALTH
~~J:~c~ 1~ AFFIDAVIT, LICENSE and
~5~lgJ~R 21 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE .-J
FROM THE GROOM FROM THE BRIDE
1. A. FUll NAME u~p n.nnr 11. A. FULL NAME Mil sA Hd~
FIRST MIDDLE RRENT SURNAME FIRST blf QA,. SURNAME
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~SN~~~~~:~~~SE) Gaynor
D. SOCIAL SECURITY NUMBER 102...s4-1Zl2
12. RESID.ENCEA. ~rcxk B. ~esl
C. CHECK ONE 0 CITY 0 ~WN 0 VilLAGE
AND .aO-.
SPECIFY",-pp"fJf'!r
D. STREET ADDRESS 2505 ROt de 9 0
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 081~
2. RESIOENCEA. _,vo,... B.~
C. CHECK ONE 0 CITY OiI'J'OWN 0 VILLAGE
AND \NIl.
SPECIFY pp~
D. STREET ADDRESS ?~ An.. 9 P
ZIP 12590
YES Mo
/1ill
ZIP 1~
o YES cVNO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 2& 13.B. DATE OF BIRTH M~ / i1
14. EMPLOYMENT
A. USUAL OCCUPATION Teller
B. TYPE OF INDUSTRY OR BUSINESS M & T Bank
15.PLACEOFBIRTH (~~York
16. FATHER
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 28 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION P.ntf""
B. TYPE OF INDUSTRY OR BUSINESS Self - Empoved
5. PLACE OF BIRTH ~~Xork
6. FATHER
A. NAME lbom_ Dee Gaynor
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME \AoloFII Marie Allen
B. COUNTRY OF BIRTH U G A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
A. NAME Jalleph David Hataling
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Cynthie .....AA l.4.A1tse
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
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
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
o
(2) 0 DEATH
o
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
o
o
o
o
t exists
o 1ST
o 2ND
o 3RD
o 4TH
be iel that the InlDrmatlon
21. SIGNATURE OF GROOM
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New 'York
Relations Law ~11 to perform marriage ceremonies within York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o II checked, this license is to be used onl urpose of a second Dr subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Domestic
~
{ SEAL }
'-.,-I
YEAR
YEAR
MONTH
NAME (PRINT)
TIME
MONTH
E
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1)( CIVIL
05 30 2004
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUNTY tM rtr'A-m
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~LLAGE..O~....L
SPECIFY ~ ^LO ! 1Izl.NC
04
01
NAME (PRINT)
SIGNATURE ~