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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM . .... .
89,m P Me F8~SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
J~ M. MU*N:TSURNAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A.___>yodc
C. CHECK ONE D CITY ~OWN
~~CIFY -=-..hlrill
D. STREET ADDRESS 10 ~ [)dye AfA 47 B ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED V1UAGE?
3. A. AGE 71 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION u~ ~
B. TYPE OF INDUSTRY OR BUSINESS Argent MOItgIge
5. PLACEOFBIRTH~.
6. FATHER
A. NAME KAVin Air.hard Mf!' F.-tane
B. COUNTRY OF BIRTH II S A
7. MOTHER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~JN~~~~t~~e~~SE) Me FaflllAe
D. SOCIAL SECURITY NUMBER 102 && 6Q59
12. RESIDENCE A. N_eY- B. QulMeB8
C. 2~5CK ONE D CITY D.;OWN D VilLAGE
SPECIFY F.hkill
D. STREET ADDRESS 1 0 C~ DrIve Af6,. 47 S ZIP 1252-4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? D YES q;NO
13. A. AGE Zl 13.B. DATE OF BIRTH McG:1 / 2Q "'1816
14. EMPLOYMENT
A. USUAL OCCUPATION PhyIIiall TheRlpiBl
B. TYPE OF INDUSTRY OR BUSINESS V..8r BIdheRI Mecl
15. PLACE OF BIRTH -N"~Ft.Jd',.)
16. FATHER
"
A. NAME Lean8Jd U8ltiA MuJphv
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jenet Marie Miller
B. COUNTRY OF BIRTH U 8 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Q5S.60..31os
8. -rJaJ;tElII
D VIIJ.AGE
12524
D YES ~NO
A. MAIDEN NAME Mary I<8therIM Sena
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
DEATH
DEATH
o
(2) 0 DEATH
o
o
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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 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
D 0
D 0
o D
o 0
at I declare that no legal impediment exists
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
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that to the best
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
D
D
D
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S person authorized by New YDrk Domestic
Relations Law ~11 to perform marriage ceremonies withi ew 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 ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR
AM
PM
11
04 2003
09
08
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF sa. TOWN OF D VILLAGE OF
SPECIFY '"BfJ..+hfe he /11 (Del YlAa..r)
10 CIVIL
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
DOH.98 (11198)
NAME (PRINT)
SIGNATURE ~