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18
STATE UI- Nt:W YUHI\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~D De ~~PSURNAME
_......... ...... ..............0
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~h E. Th.ENTSURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
D.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~JN~~~~~~e~~SE) De stefano
D. SOCIAL SECURITY NUMBER 1 03---7Q..61 08
12. RESIDENCEA'~SXTE) B. Q~e&1
C. CHECK ONE 0 CITY 0 "oWN 0 VILLAGE
AND W .
SPECIFY . apptnger
D. STREET ADDRESS 39 tv'artin Olive ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13.A. AGE 21 13.B.DATEOFBIRTH M~ / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Paralegal
B. TYPE OF INDUSTRY OR BUSINESS RosIcki 3. Assoc.
15. PLACE OF BIRTH (Pn9.\~'~liP' York
16. FATHER
A. NAME Jeffrey Christopher Theiss
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Syssn JaA8 HaASen
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A.
302..74-2097
B. ~5S
QfrOWN 0 VILLAGE
~;tE)
C. CHECK ONE 0 CITY
AND
SPECIFY BAAr.nn
o STREET ADDRESS S n Snllth StAIlhP.n COllrt ZIP
12~08
12590
YES D~O
/1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
DYES o.'No
MON
...
:>
~<t
C
u:
....LL
<t
A. USUAL OCCUPATION Facto~ Worker
B. TYPE OF INDUSTRY OR BUSINESS Koshll Mexel1lm Amer Inc
5. PLACE OF BIRTH ('Jnl'lnnatl nhln .
(~,S~USA)
6. FATHER
A. NAME Gary Dt- stefel'10
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME Mary Holmes
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
DEATH
o
(2) 0 DEATH
o
o
o
(3) 0 ANNULMENT
/ /
B. HOW 010 LAST MARRIAGE END? (3) 0 OIVORCE
C. DATE LAST MARRIAGE ENDED?
8. HOW 010 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
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
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 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH - 0 0
nowledge and belief that the information I provided is tru~ :hat I, declare that no legal i~Pediment exists
22. SIGNATURE OF BRIDE ~ '- ~ {~ ~ 01;} r
. U~E ro~JT 'N1ME
DATE 03I19f.2004
by New YDrk Domestic
w
en
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(.)
:::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authDrizes the marriage in New York State of the bride and groom named above by any persDn authorized
Relations Law ~11 to perform marriage ceremonies within New York 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
NAME (PR~
SIGNATURE ~
MAILING ADDRESS
05
18 2004
~
{ SEAL }
'-v-I
YEAR
YEAR
TIME
MONTH
DATE
11 :3!t~
03
20
ZIP
TE
27. TYPE OF CEREMONY
o ~GIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE ARRIAGE OCCURRED (
A. STATE NEW' YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY UJ()!f'11J€u ~(//I5"
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 0 CIVIL
29. OFFICIANT
NAME (PRINT)
TITLE
STATE
NAME (PRINT)
SIGNATURE~
DOH-98 (11/9B)