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COUNTY ~
CITYfTOWN w.ppI~
DISTRICT 1~
NUMBER
~5~~l~R 1~
STATE OF NEW. YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE CSROOM '
'""'mi~tt J U-~i!9 SURNAME
I
STATE FilE NUMBER
. (THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
11. A. FULLNAME FIRST EU5r"EL Di C~ENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT BARght
C. S~SN~M,r~~~~~O~~SE~'aBaslIO
D. SOCIAL SECURITY NUMBER 101-5&-9458
12. RESIDENCEA. NU-)'- B. q~B
C. CHECK ONE 0 CITY o;rOWN 0 VilLAGE
~~CIFY POlIgb~e
D. STREET ADDRESS 1782 South Road Lot '1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MQa / '\av 4Qi'l
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER [)62.S:4.. 3874
2. RESIDENCE A. NS'MEYodr B. ~eIIl
C. CHECK ONE 0 CITY IjjjI'TOWN 0 VILLAGE
AND P 1I"Ihw-nai
SPECIFY nt V -=_~~.y-f!!
D. STREET ADDRESS 17~ $nllth RoAd lot 31 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!ii NO
3. A. AGE 32 3B. DATE OF BIRTH MJii / m / WO
4. EMPLOYMENT
A. USUAL OCCUPATION Chemi~ ~or
B. TYPE OF INDUSTRY OR BUSINESS E~eblrd Corp
5. PLACE OF BIRTH ~~X~SA)
6. FATHER
A. NAME .~ Rt~ V-Bellp
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME ThertII LouIs. Trotlno
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
A. MAIDEN NAME G1evabellelArr8lne Strombe"
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) MIVORCE . (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONT))Z /" / .1
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1ST 02Q712OO1 PoughkMpsle, Ne\"J YoFk 0 [if'
2ND 0 0
3RD 0 0
~ 0 0
at e in ormation I provided is true and t at declare that no legal impediment exists
22.SIGNATUREOFBRIDE~ ~~~ ~.(S<~~~
U~
13.B. DATE OF BIRTH
13. A. AGE 41
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher's Aid
B. TYPE OF INDUSTRY OR BUSINESS a.con CIty Sdl. DIll
15. PLACE OF BIRTH ~...~~.. York
16. FATHER
A. NAME Fl1Inds Ennght
B. COUNTRY OF BIRTH USA
17. MOTHER
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
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
0:
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21. SIGNATURE OF GROOM
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 1Q106l2(V'3
This license authorizes the marriage in New York authorized by New York Domestil
Relations Law 911 to perform marriage ceremonies wi New 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
~
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
AM
PM 10
07
12
05 2003
28. PLACE WHERE MARRIAGE OC~RF~ L-__
A. STATE NEW YORK B. CO~
C. LOCATION OF CEREMONY
(CHECK E AND SPECIFY)
STR ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDI
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~ ·
DOH-98 (11198)
NAME (PRINT)
SIGNATURE ~