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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE ALE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
.cduNTY ~
CITYfTOWN ~pp1"QN
DISTRICT 1~
NUMBER
~~~~J~R 1~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
..J
I, A. FULL NAME
~ J LENT SURNAME
FIRST
11. A. FULL NAME
QRJrah L ~NT SURNAME
FIRST
11.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIALSECURITYNUMBER 091...]2..64]6
2. RESIDENCE A. "tm)Vor.k B.~
C. CHECK ONE 0 CITY [)frOWN 0 VilLAGE
AND Wa.
SPECIFY ppnger
D. STREET ADDRESS 69 Brotbef5 Road
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I -Id
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 10& 88 0015
12. RESIDENCEA. NM!wE;fcuk: B. ~esB
C. ~fiCK ONE 0 CITY 0 ~WN 0 VilLAGE
SPECIFYV'lappiRger
D. STREET ADDRESS S; Broth_ Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES C1i'NO
13. A. AGE 29 13.8. DATE OF BIRTH M<fJ2 /1A1 "'1&7.4
14. EMPLOYMENT
A. USUAL OCCUPATION C8B8 Manager
B. TYPE OF INDUSTRY OR BUSINESS P. F. C. S.
15. PLACE OF BIRTH ~~UNlwN~.
16. FATHER
A. NAME 'Jasil}.' Deeu
B. COUNTRY OF BIRTH U S ,A.
17. MOTHER
ZIP 12590
DYES Qp1'NO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Aa:aunt
B. TYPE OF INOUSTRY OR BUSINESS Rt;lRtron Phlr-m.
5. PLACEOFBIRTH~.
6. FATHER
A. NAME J08eph Laski
B. COUNTRY OF BIRTH P-OIlnd
7. MOTHER
A. MAIDEN NAME Helen KulII8
B. COUNTRY OF BIRTH PoI8n~
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
A. MAIDEN NAME JtlcIth Ann Mortensen
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
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
(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
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
U
::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that nD legal impediment exists
as to my right to enter into the m ge te. ~
21. SIGNATURE OF GROOM ~ SIGNATURE OF BRIDE ~ ~....... h c!:l, kl".,l>\ L.J.....
. . USE~NAME' -
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State 0 authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne ork 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
~
{ SEAL }
"-v-I
NAME (PRINT)
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
TE
AM
PM
11 14 01 12 2004
28. PLACE WHERE MARRIAGE OCCURRED
STR
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ZIP
ATE
27. TYPE OF CEREMONY
o i2!: RELIGIOUS
9 0 OTHER, SPECIFY
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10 CIVIL
A. STATE NEW YORK B. COUNTY l)lrt\:~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF IX TOWN OF 0 VILLAGE OF
SPECIFY €vt* t;~ k.k l\ \
:('q
03
TITLE ~l)Illf:ll rdil,'c- VOv~p,~f
DATE v\'(W. J. CI ;;tm 3
I
A A'\1 €N?4-
SIGNATURE ~
-~