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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Cam~
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK. DATE DQ/1~~
This license authorizes the marriage in New York S bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used onl ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ . } NAME (PRINT) Gloria J. MonIe
tJ TIME MONTH YEAR
SEAL SIGNATURE.-
M~gsebLBh R
'-v-I s
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
COUNTY ~
cirvrrowN 'War.dnaer
DISTRICT 1 ~
NUMBER ~
~5~I:J~R 125
1. A. FULL NAME
FIRST
II.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER
2. RESIOENCEA. ~~Erork B. ~
C. CHECK ONE 0 CITY 0 TOWN [!l"VILLAGE
~~CIFY WaDDinaeIB Falls
D. STREET ADDRESS 9 stuart Avenue ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? c1'YES 0 NO
3. A. AGE 21 3B. DATE OF BIRTH 01 / 11\ / 1M?
MONTH DAY ym-'
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Arom. Osten.
5. PLACE OF BIRTH Teoometl.n. PuebI. Mexico
(CITY, STATEICOUNTRY IF NOT USA)
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6. FATHER
A. NAME Jorae CIImDDB
B. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME CArmAn GamlA
B. COUNTRY OF BIRTH Mexleo
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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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rnr.in M Marti
MIDDLE ~NT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ca"'pDS
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~]4.. 3532
12. RESIDENCE A. ~tnrk' B. q~1I
C. CHECK ONE 0 CITY 0 TOWN [)wIl.JILLAGE
~~CIFY WRppi9"' FallA
D. STREET ADDRESS 9 stuart AVAnUA ZIP 12t\Q()
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 20 13.B. DATE OF BIRTH Mc11 / 4i -1~
14. EMPLOYMENT
A. USUAL OCCUPATION AuperviKor
B. TYPE OF INDUSTRY OR BUSINESS Foam & Wasb car Wasb
15. PLACE OF BIRTH "CD~ Ip.
16. FATHER
A. NAME Antonio M.rtinmo
B. COUNTRY OF BIRTH MAVIM
17. MOTHER
A. MAIDEN NAME Micelle PeslAI
B. COUNTRY OF BIRTH MaxI()()
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
o
o
22. SIGNATURE OF BRIDE.
IP
09:49AM 09
PM
YEAR
18
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1 W' CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY~~"
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.