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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.ev p. ChMlNT SURNAME
COUNT'V Dlld:le'SS
CITYITOWN WaPPRger
DISTRICT 1 S68
NUMBER
~5~I~J~R 131
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) .... "_~_54~"'7
D. SOCIAL SECURITY NUMBER -1-1 -1....,......-
2. RESIDENCEA.____IVark B. -~i1BB
C. CHECK ONE 0 CITY 0 TOWN Q,I'IIILLAGE
~~~CIFY \NIIppingelS Fall.
D. STREET ADDRESS 2603 South Av.nue 2nd Fl.zlP 12S80
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? []ffES 0 NO
3B. DATE OF BIRTH
M
3. A. AGE 241
4. EMPLOYMENT
A. USUAL OCCUPATION Rtlllidential CauRBelar
B. TYPE OF INDUSTRY OR BUSINESS HudloA RIver Hung
5. PLACE OF BIRTH DA........~.. ..MewYcmc
~J
6. FATHER
A. NAME Philip MargllR Chale
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judth 'nn Kennedy
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
(2) 0 DEATH
o
o
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
;:tll'\'c' rl&..c;; f..umg~n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jllli.. A R. h ..
~. - BlR .!mIIT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~JN~~~~~~e~~SE) Chase
D. SOCIAL SECURITY NUMBER 071 7-4 1387
12. RESIDENCE A. _Er- B. ~esB
c. CHECK ONE 0 CITY 0 TOWN D.,ILLAGE
~~CIFY \NappiRgeJB F.al1B
D. STREET ADDRESS 2603 South Avenue 2nd Fl. ZIP 12S0
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D,l'VES 0 NO
13. A. AGE 25 13.B. DATE OF BIRTH MM / G9 "'1ilB
14. EMPLOYMENT
A. USUAL OCCUPATION TeaGher
B. TYPE OF INDUSTRY OR BUSINESS 8yWIA LelmlAI Center
15. PLACE OF BIRTH Jq,Qt~~_~stJ~.J York
16. FATHER
A. NAME Rabeft Child. ReinhaRt
B. COUNTRY OF BIRTH U 8 A
17. MOTHER
A. MAIDEN NAME Anno Merle Derry
B. COUNlTRY OF BIRTH U S ,A,
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o 0
B. HOW 010 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
pediment exists
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en
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BE ME
SIGNATURE OF TOWN OR CITY CLE K~ DATE 09Q3Q003
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit 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
o
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en
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~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
22. SIGNATURE OF BRIDE
25. B. SOLEMNIZATION'PERlm
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR
MONTH
DAY
YEAR
ZIP
09
24
11
22 2003
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A E
27. TYPE OF CEREMONY
o ~L1GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~l.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF fit TOWN OF 0 VILLAGE OF
SPECIFY ~~~
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
DOH.9B (11198)
DATE
Rev.
lo/t~/o3
.
Il S$"o
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) J~NL~~
SIGNATURE ~
