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COUNTY DutcheSS
CITYITOWN Y'appinger
DISTRICT ·
~~~I~~~R 13GB
NUMBER 141
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
l'J')Q{nas J. Kri*NT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kar'l!~isoR Ma~SURNAME
1. A. FULL NAME
11. A. FULLNAME
FIRST
FIRST
"-
N
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ., fiskD
(OPTIONAL - SEE REVERSE)""
D. SDCIAL SECURITY NUMBER 131 7(}9150
B. ~~s
o VILLAGE
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 594 1& 1929
2. RESIDENCE A. NSVTE) B. ~CS8
C. ~~6CKONE 0 CITY ~TOWN 0 VILLAGE
SPECIFY '1lappingcr
D. STREET ADDRESS 10 Gel)' Pleee
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE?
12. RESIDENCE A. N (~ATE)
C. ~~6CK ONE 0 CITY q,.,rOWN
SPECIFY \Napping8r
D. STREET ADDRESS 10 Gary Place ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 'i3I NO
Mo1,1 / QI ~~,
3B. DATE OF BIRTH
13. A. AGE 24
14. EMPLOYMENT
13.B. DATE OF BIRTH
ZIP
o
3. A. AGE 23
4. EMPLOYMENT
A. USUAL OCCUPATION Canstftldian
B. TYPE OF INDUSTRY OR BUSINESS M & M Censt.
5. PLACE OF BIRTH B..._"tN.. x.
6. FATHER
A. USUAL OCCUPATION Secr8tarial
B. TYPE OF INDUSTRY OR BUSINESS At Your ServIce
15. PLACE OF BIRTH ~~~~ ~~
~C , tlr A
16. FATHER
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A. NAME RobeIt Jahn Markham
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Anne VieteFia Height
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
A. NAME Thomas Allen Krisko
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME 81en Lynn Kiefer
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o
o
o
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE lAST MARRIAGE ENDED? / /
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
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 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 an
as to my right to enter into the marri~~ state. 1\'
21. SIGNATURE OF GROOM ~ \ ~ I ~ 22. SIGNATURE OF BRIDE ~
CURRENT NAME
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.23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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
DATE 1Q1D6f2On~
by New York Domestic
~
{ SEAL}
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
12
05 2003
10
07
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF -S"'TOWN OF 0 VillAGE OF
29. OFFICIANT
NAME (PRINT)
SPECIFyiAJ1f/I)YA..
SIGNATURE ~
SIGNATURE ~
nnJ-l_QA (11IOA\