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COUNTY DItcl\e5$
.CITWTOWN Wepplnger
DISTRICT 1368
NUMBER
~5~~J~R 120
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ R ~~URNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~r:n.rWfe l Pll~nn
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 44 E DR -9594
D. SOCIAL SECURITY NUMBER -I-I~-I
2. RESIDENCE A._____~odc B. ~m
C. CHECK ONE D CITY [ifTOWN D VilLAGE
~~CIFY C>nn"
D. STREET ADDRESS 38 Drew LIne
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Greene
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 071.72.9600
12. RESIDENCEA. ~~)Yadr B. ~efIfI.
C. CHECK ONE D CITY OrIIItOWN D VilLAGE
~~~CIFY R8.hldll
D. STREET ADDRESS 29 ~ ROId ZIP 12~A
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r::J' NO
MO~ /11 /-1m
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 10512
D YES r3I NO
E.
13.. A. AGE 25
14. EMPLOYMENT
A. USUAL OCCUPATION ~m~ Rnnm TP-clI
B. TYPE OF INDUSTRY OR BUSINESS at Francis Hosptlf
15. PLACE OF BIRTH -"5UJm!~ I"K)'-
16. FATHER
A. NAME Pal" "1I7'7IIr.nnP-
B. COUNTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME Janet Puclno
B. COUNTRY OF BIRTH II S A
lB. NUMBER OF THIS MARRIAGE 2
3B. DATE OF BIRTH
13.B. DATE OF BIRTH
3. A. AGE 25
4. EMPLOYMENT
A. USUAL OCCUPATION ~ MAcluanir-
B. TYPE OF INDUSTRY OR BUSINESS Carmel Cntd SChools
5. PLACE OF BIRTH ~~ X~)
6. FATHER
A. NAME Robert INing Greene
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME ElIzI~ P.m". Wemer
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) D~VORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 05 / ~ / ~
MONTH or ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? olll!\::s D 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
~ nJltm- l'..nJlnty, NfMt D
\' I
D
D
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
2ND
3RD
4TH
I, being duly swom, depose and say,
as to my right to enter into the mar'
21. SIGNATURE OF GROOM ~
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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 Stat
Relations Law ~11 to perform marriage ceremonies within
D If checked, this license is to
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
used only for the urpDse of a second or subsequent cerBmony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-.-'
TIME
MONTH
YEAR
YEAR
AM
02:33'M
09
08
IP
l~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY k~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) L
D CITY OF 0 TOWN OF ~ VilLAGE OF
SPECIFY
NAME (PRINT)
SIGNATURE ~