139
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Iggnn P Mar .
MIDDLE ~R'ENT SURNAME
J _ COUN'rY Dutch~
, CITYfTOWN \Nappi.,
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23. SUBSCRIBED AND SWORN T EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York person authorized by New York
Relations Law ~11 to perform marriage ceremonies wit n New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used onl ur ose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~'39
2. RESIDENCE A. ~ VoW B. ~eIIl
E)
C. CHECK ONE 0 CITY [il'TOWN 0 VILLAGE
AND \I\hiI.
SPECIFY PJ'I"CJP-'"
D. STREET ADDRESS 1 A1 ~IvAl' ~OAd f\It'JI'th "IX.tIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MONW / l' / y1Q78
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3. A. AGE 24
4. EMPLOYMENT
A. USUAL OCCUPATION IlInd $lIN~
B. TYPE OF INDUSTRY OR BUSINESS SIcily & watson
5. PLACE OF BIRTH -Pc~~~York
6. FATHER
3B. DATE OF BIRTH
A. NAME AnhMt S:rII~ "'.pi"
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME LlUfl Clcerlllo
B. COUNTRY OF BIRTH II S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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21. SIGNATURE OF GROOM ~
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{ SEAL }
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STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
'SER M. ~RENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~i~~~~t~~e~~SE)MI1Iizi.
D. SOCIAL SECURITY NUMBER 1Q5..66.-3837
12. RESIDENCEA. NMlat:lc B. ~~S
C. CHECK ONE 0 CITY o.;rOWN 0 VILLAGE
AND 'A'" .
SPECIFY v_ppnger
D. STREET ADDRESS 2 F.-more DrIve ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES W NO
Mol;a / 01 ~ai6
13. A. AGE 26
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION \Jisulll Mera.anciziRg
B. TYPE OF INDUSTRY OR BUSINESS Fllene's
15. PLACE OF BIRTH -@~~ ~
16. FATHER
A. NAME Ja8eph James WeaIy
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME MIry CatheFlne Byrne
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
000
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
o 0
o 0
o 0
o 0
ga impediment exists
22. SIGNATURE OF BRIDE ~
Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
10
07
12
05 2003
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURR~ f
A. STATE NEW YORK B. COUNTYJ)1.(f"t,(~5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF [!(' VILLAGE OF
SPECIFY~1'~ F4//(
:3l? , I 03
29 OFFICIANT 1/1 I .1 Il. G II .f,' IL'I,L
NAME (PRINT) fI( DblYT /Cen!"'tll 1Il1 JJ TITLE It'11-tti t:.,...-' ""
SIGNATURE~ " CrI,',.fDh' ~fr~ef ~i.{,I(.~ I New D3
MAILING ADqRESS L. II "" ~b
(,Ja,,,Jt'tUyJ rr.{f(~ III r J",7'O
STRrtE1 -r- CITYfTOWN STATE
30. WITNESS TO C REMONY,
SIGNATURE ~