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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.1Aann Uil!hsJP.l UilliP.l'
MIDDLE CURRENT SURNAME
~
COUNlY Dutchess
CITYfTOWN WlppI...
~~J~c: 1388
~5~~~R 1
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 711..1"-7757
2. RESIDENCEA.~ B.~9'
C. CHECK ONE '''''ti; CITY 0 TOWN 0 VILlAGE
~~~CIFY Arandon
D. STREET ADDRESS 1~1~ VAr!U!lInt OrIvA AP- ~P
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? r:Y'YES 0 NO
3. A. AGE 71 38. DATE OF BIRTH ~ / i9 / jj76
4. EMPLOYMENT
A. USUAL OCCUPATION Medcal Bilt Reviewer
B. TYPE OF INDUSTRY OR BUSINESS Ri'W HeaIt)t Inc
5. PLACEOFBIRTH~'~
6. FATHER
I- A. NAME Robert Cbades Miller
~ B. COUNTRY OF BIRTH II S A
c 7. MOTHER
IE A. MAIDEN NAME Debra Jlln JIItI.
lIl( 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
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I iSUI U ~r.o
MIDDLE CURRENT SURNAME
.J
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Miller
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER n57 _77..57~
12. RESIDENCE A. ~flNIr B. ~grm9'
c. CHECK ONE []ot'CITY 0 TOWN 0 VilLAGE
~~CIFY Rrandon
D. STREET ADDRESS 1~1~ VAr!U!lInt OrIvA AP- ~IP 33511-88
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE? [Y'YES 0 NO
13. A. AGE 31 13.B. DATE OF BIRTH Jtl / ~ /<i~
14. EMPLOYMENT
A. USUAL OCCUPATION Administnftnr
B. TYPE OF INDUSTRY OR BUSINESS E Me,
15. PLACE OF BIRTH ~_J;.
16. FATHER
A. NAME Robert 1bomas Sivco
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME BlrblfI MlrltA. AVCZIAO
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
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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 1ST
o 2ND
o 3RD
o 4TH
lef that the Information
o 0
o 0
o 0
o 0
lare that no legal impediment exists
23. SUBSCRleED AND SWORN TO BEFO E ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 011D612OD4
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the U ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-v-I
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
22. SIGNATURE OF BRIDE
TIME
MONTH
YEAR
MONTH
YEAR
D9:1<~
07
03
06 2004
01
CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~
C. LOCATION OF CEREMONY
(C~CK ONE AND SPECIFY)
~ITY OF. 0 TOWN OF 0 VILLAGE OF
SPECIFY
NAME (PRINT)
SIGNATURE ~