124
COUNTY Ol-tchesE
CITYrTOWN \.AJappnger
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n5~~J~R 124
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
\..~Jav~JaeksBA Q~lURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FUll NAME
11. A. FUll NAME
FIRST
Tania Ladle CtlllllENT SURNAME
FIRST
~ B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE n' ....-'1
(OPTIONAL. SEE REVERSE) (OPTIONAL. SEE REVERSE,., ~
D SOCIAL SECURITY NUMBER 067 72 nfIl D. SOCIAL SECURITY NUMBER E:J69.64..0337
2. RESIDENCE A. N1X.TE) B. ~ess 12. RESIDENCE A N ~ATE) B. ~
C. CflECK ONE 0 CITY ~ TOWN 0 VillAGE C. ~~6CK ONE 0 CITY ~ TOWN 0 VillAGE
AND Wa'
SPECIFY ppnger SPECIFY \fJappinger
D. STREET ADDRESS 16 A Wnthrop Court ZIP 1259Q D. STREET ADDRESS 16 ,. V'Anthrop Court ZIP 12590
E. IS RESIDENCE WITliIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES Iiiil' NO E. IS RESIDENCE WITfllN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE 30 38. DATE OF BIRTH MOH) / 7J / tiJ12 13. A. AGE 24 13.8. DATE OF BIRTH a / OBy 191.&
4. EMPLOYMENT 14. EMPLOYMENT
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A USUAL OCCUPATION Machine Operator
B. TYPE OF INDUSTRY OR BUSINESS IBM COil)
5 PLACE OF BIRTH ~~FY~*)
6. FATHER
A NAME Frank A. 0' Dell
B COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME GeFtRKle L PFesher
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
o 0
B. flOW DID LAST MARRIAGE END? 13) 0 DIVORCE
A. USUAL OCCUPATION Maehine Operator
B. TYPE OF INDUSTRY OR BUSINESS Phllllp's Semiconductor
15. PLACE OF BIRTH Qfo."~~_USA)
16. FATHER
A. NAME Jaseph CI'tIE
B. COUNTRY OF BIRTH U & A
17. MOTHER
A. MAIDEN NAME YoIlnda Echvarrla
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
DEATH
o 0
B. flOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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(2) 0 DEATH
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12) 0 DEATH
C. DATE lAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
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
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2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 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 and that I declare that no legal impediment exists
as to my right to enter into the marriage st~e. L'\ ~
21. SIGNATURE OF GROOM ~ W 22. SIGNATURE OF BRIDE ~ ........J0I\1.t6/. tR1 (0 ~-
t u~ CUI"! NAME ~
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 by New York Domestic
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
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
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{ SEAL }
'-v-I
YEAR
TIME
MONTH
DAY
YEAR
MONTH
DAY
AM
PM
10
2003 11
08 2003
09
STREET
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 cou,..d;?ct12~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VillAGE OF
SPECIFY W /lttJp /;,,b'U'Z-
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE ~