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COUNTY Dlictt I n
CITYITOWN ~~..,
DIS~ICT 1388
NUMBER
~5~~J~R 15
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I STATE FILE NUMBER
I (THIS SPACE FOR STA TE USE ONL Y)
flllJtd t// ~/ltJlf
;f~-1t'67
L [] SUPPLEMENTAL FILE
--1
I
1. A FULL NAME
J- Dh I.tk:I'.-a U --!I .R.
-'MIDDLE CURRENf SURNAME
FROM THE BRIDE
Michele D. VaBiIIa
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Ai77n
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
FIRST
11. A. FULL NAME
"-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) nRIfL, __ "Eft"7
o SOCIAL SECURITY NUMBER _~
2 RESIDENCE A New Yartr B n..h~__
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND ~
SPECIFY ~
D. STREET ADDRESS ~ Ro8d
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
129-66-0698
12. RESIDENCE A. New York B. n..t~
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 IltIbWN 0 VILLAGE
AND ~
SPECIFY ~
D. STREET ADDRESS vvencr Ro8d
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
CJ1 / 17
MONTH DAY
ZIP 12580
o YES ~NO
12580
YES 0 ~O
/1QRQ
YEAR
ZIP
3. A. AGE
33
13.8. DATE OF BIRTH
38. DATE OF 81RTH
~.
13. A. AGE
>-
f-
4. EMPLOYMENT
A. USUAL OCCUPATION RAr.fririsut
B. TYPE OF INDUSTRY OR BUSINESS J M V ~
5. PLACE OF BIRTH PM ~ New V_
(CITY, STA~NOT USA)
6. FATHER
A. NAME .~ ~ V~. Sr
B COUNTRY OF BIRTH U $ A
7. MOTHER
A. MAIDEN NAME a..enor. DouI:lIeIe
B COUNTRY OF BIRTH CInIcII
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
14. EMPLOYMENT
A. USUAL OCCUPATION HarnernaIcer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Branx NewV_
(CITY, STAT~COUNTRY IF NOT USA)
16. FATHER
A. NAME J-~ Ab7n
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dora QOIIOh
B. COUNTRY OF BIRTH GIrrnInv
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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, STATElCOUNTRY, 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
1 ST 0 0 1 ST 0 []
2ND 0 0 2ND 0 []
3RD 0 0 3RD 0 [J
4TH 0 0 4TH 0 0
I, bemg duly sworn, depose and say, t to the best of my knowledge and belief that the mformatlon I provided IS true and that I declare that no legal Impediment eXists
as to my nght to enter mto the marri state. t/r V3( . 11 t /.
21. SIGNATURE OF GROOM ~ ;,., "I ,( ~ 22 SIGNATURE OF BRIDE ~ _ / ~ 0 IIlJ .l.fl.i1f 110
U ENT USE Cffi1RENT "AME
23 SUBSCRIBED AND SWORN TO B ORE ME ~
SIGNATURE OF TOWN OR CITY CLERK ~ DATE ~_~_~_...
This license authorizes the mar;ciage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform;nlfriage ceremonies within w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
r-r 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
~
{ . '. . }... N.. AM.E (PRIN.T)
SEJ\k, . ~'J~~iR .
:'\:' . MAldN~AIi
~ '.
'., STAE
I 'Cj"RTIF.y THAT I SOLEMNIZED
~ MAR~!AGE OF THE PER
.sONS NAlJilED fJOVE ON THE
'll'IITE Ar-/!), Nt' I> TIME 1{'ID
PLAC/' IIllDlCM D' I r' r i ,- t
~ :'7:<~I:-.~r - ~ )
~OFflCGi:I,,,,, . -,l:J.\...'1.' .'
NAM\E (~~,t' I} J/~, ;j>l.L~. \
r; /~~"-' .r;;~_~~>..~<(~:.(~, ..~~_
SIGNA'fURE~' .' ifl,_.' ~,
MAILfNC}A9PRESS.C,;.," " (
'_.~ r(.\
STREET .
30. WITNESS TO CEREMONY
TIME
MONTH
YEAR
MONTH
YEAR
AM
03
0&
05
f11 2004
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1 D CIVIL
A STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
AM
PM
TITLE
DATE
SPECIFY
CITYITOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~
6/23/2004
Called and spoke with "Michelle" as to the
status of this marriage license.
Did NOT use this license in the 60-day
-
time frame. (License only valid until
5/7/2004.)
However, they were le~allv marrie~ in a
civil ceremony on June 28, 1998.
'--- - -----..
Because they were christening their
newborn in the Church On March 21, 2004,
the Priest wanted them to have a Church
Ceremony and that is why they applied for
a marriage license on 3/9/04. They were
married in the Church on June 6, 2004 _
~ a "marria~l;) License,"
~
~
~
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6/24/2004
of
's - Village
St Mary . th
The Priest fromlled and spoke w~ad
Wapp. Falls, ca lained that be 6/6/04
G Morse and exp h Marriage on d
. b Churc . ban _
erformed t e tbe license ~n
p didn't bave bring 1t.
but tten to .
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. d that the b d exp1red.
We expla1ne. ce tbe license a
Not Valid S1n license
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ld bave to ap~ Y)' order for t e
They wou . d (aga1n 1n
b remarr1e 'd
and e . t be val1 .
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IIIRL~I O! RU'ORIIS A'IJ Sl.\T1STI('S
CERTIFICATE OF BIRTH ~EGISTRATION
'1II1S h '01 ., /" 8TIIIH' ('0'" SH' 11I.1.0\\,
.....
r
;JlOVE IS AN KU.:r COPY CF 1. :OOIl'ICJ.TE OF BIRTH REX;ISTmED FOR YCUR CEILt.
l'l' IS SI!~1',mBOOr CHARGE, TO ALLO.... Yor TO CIDJ::K THE ;..CCURJ"CY OF THE RF.PORDF:D
:N1ORN.TION. IJl' THE CERTlJ'ICJ.TE CONTAINS .lJlY mRORS, RF:I'ORlI THIS COPT IoTl'H r<...B;
CORRm=T INFQRlU.TIOIl TO TIlE DIVISION OF R&:ORllS IN THE BOROUGH W1l!RE THE CHILD
WAS BORll. (SEE ;JlJlRg)S B~LO"".) YOO WlLL BE AllVISED BOil TO IU.VR THE R!l:ORD COR-
RiCTKD. I1' IS IMPORTANT TO 00 THIS AT ONCE..
*,\ COPY BBlRING THE RJ.ISKD SElL OP THE DKPAR'I'MEIlT OP H&.\LTE JW' BE OIlT:.n!):;)
UPON PJ.YKFIiT OF '!'HE RI!QOITtKD PEE WID!2lEVlR I1' IS n:KIlED FOR OFPICUL PROOl' OF '~HR
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