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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST ~~D~P.phen P=~=AA~~
COUNTY outch~
CITYrr~WN Wappl~
~~J:~~ 1_
~5~~J~R 15S
1. A. FULL NAME
B. BIRlH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 nR-fi(). 7?7 4
2 RESIDENCE A. ~m~ork' B, g!~P-lIK
C. CHECK ONE 0 CITY 0 TOWN [)l'VILLAGE
~~~CIFY WliIppin~..I1I FIllIA
D. STREET ADDRESS ~ North Gilmore BaulevardlP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? o;'vES 0 NO
3. A. AGE 26 3B. DATE OF BIRTH MO~ / ~ / y1F7
4. EMPLOYMENT
A. USUAL OCCUPATION PI"nI'!f!!lUL Opendor
B. TYPE OF INDUSTRY OR BUSINESS I. B lP4
5. PLACE OF BIRTH ~oX-9t
6. FATHER
A. NAME ThANfnrf!! Qt~P-n pfl!trncirm .Ir
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME MIIIII. LouIs. Le\AJ1c
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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(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
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
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
PatriciA K ~OnR
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~nna
(OPTIONAL. SEE REVERSE) ~ ~A n~~
D. SOCIAL SECURITY NUMBER ~~
12. RESIDENCE A. Np-w Vork' B. nllt,..,fI!SUl
(mTE) ~)
C. CHECK ONE 0 CITY 0 TOWN [)jIIIILLAGE
~~CIFY WliIppingel'K Falls;
D. STREET ADDRESS ~ North Gilmore Baulevard-IP 12lmO
E. IS RESIDENCE WITHIN L1~ITS OF CITY OR INCORPORATED VILLAGE? c.'YES 0 NO
13.A. AGE 25 13.B.DATEOFBIRTH~ / m A~p
14. EMPLOYMENT
A. USUAL OCCUPATION T~r
B. TYPE OF INDUSTRY OR BUSINESS ...umpty Dumpty ~
15. PLACE OF BIRTH -e~ York'
16. FATHER
A. NAME \Mllillm R-.,i()ftR
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME &enh. Taylor
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
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
o
o
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
o 0
o 0
o 0
t 1 declare that no lega Impediment exists
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1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St
Relations Law ~11 to perform marriage ce:remonies within ew 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
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{ SEAL }
'-.t-I
NAME (PRINT)
DATE 11In..'VXV\,,~
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
11
04
01
02 2004
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ATE
27. TYPE OF CEREMONY
O~L1GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~'r(ftvff
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 4fTOWN OF 0 VilLAGE OF
SPECIFY ~f,tJM e
29. OFFICIANT
NAME (PRINT)