003
I-
Z
W
en
w
III
o
..J
::l
o
:r:
en
z
o
~
a:
I-
en .
C3
w
a:
w
Cl .
<(
ii:
a:
<(
::;;
u.
o
W
I-
<(
()
u:
;::
a:
w
()
w
a:
w
:r:
s:
en
en
w
a:
o
o
<(
>-
u.
U
W
0-
en
\. ~
"-_/
Zrz
gj!::Q W
lii~~ t-
~ ffiz- -c(
gJ5~ 0
~~g ~
z- -
S;~u. t-
~!QO a:
15~g? W
W~<3 0
b~"'
z~~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Chrifd:~r R Raker
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is 0 be used only for the purpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
::!
COUNTY ~
CITYfTOWN Wappl(\gef
~~J~~'i[ 1388
~5~I~l~R 3
. '
1. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
n7~1:\1
2. RESIDENCE A. "i~) Vnrlc: B. ~f!!Ul.
C. CHECK ONE 0 CITY o.;rOWN 0 VILLAGE
AND
SPECIFY Hyde PArk
D. STREET ADDRESS 21 f-401t Road
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE?
3. A. AGE 21 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION CuRtnrnfM" RP-nri~
B. TYPE OF INDUSTRY OR BUSINESS Cell One
5. PLACEOFBIRTH~Ork:
6. FATHER
A. NAME Robert N Baker
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Deborah Joan Smith
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
ZIP 125~
DYES o.'NO
o
o
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 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
o
o
o
W
en
z
W
o
::i
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRES
STR
t CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.Jennifer A Malbl'ia
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE RalcAr
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 os. n.OQ11
12. RESIDENCE A. ~mrnrfc B. ~f!!!:UI
C. CHECK ONE 0 CITY 0 fi/OWN 0 VILLAGE
AND ,.,_.
SPECIFY v-.ppn~
D. STREET ADDRESS 4R.A OrlvA ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0
13. A. AGE "'s 13.B. DATE OF BIRTH nR / ox:
-I MOmJ!i" ~
125M
YES O~O
/1R15
14. EMPLOYMENT
A. USUAL OCCUPATION ~mAil
B. TYPE OF INDUSTRY OR BUSINESS PdcelfJS! KIds
15. PLACE OF BIRTH I)...., U'Ih~I.. t\Law York:
~OT~
16. FATHER
A. NAME Robert F Malizia
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Laura Clcerello
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o
1ST
2ND
3RD
o
o
o
TIME
MONTH
YEAR
MONTH
YEAR
02
03
04
02 2004
ZIP
1 tI'c,VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~
C. LOCATION OF CEREMONY
~H~~ ~;_el:;:c~~) 0 VILLAGE OF
SPECIFy~il.....
NAME (PRINT)
SIGNATURE ~