117
1. A. FUU NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST ,-l eamPAIINT SURNAME
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(THIS SPACE FOR STATE USE ONL Y)
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l' COUNTY f"kJMh1M.C.
CITYITOWN ~"""
DISTIllCT III tIlIIeO
NUMBER I~
~5~~J~R 117
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
I irvba M C II
'lII1mIT" ill ~RENT SURNAME
11. A. FUU NAME
ARST
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B. BIR'TH NAME, IF DIFFERENT
C. SURNAME AFTER IAARRIAGE
(OPTIONAL - SEE REVERSE)
D. ,SOCIALSECURITV.NUMBER ~14'3
2. RESlDENCEA.~)Y_ B.~
C. CHECK ONE 0 CITY lJfTOWN 0 VILlAGE
AND ,."".
SPECIFY y-pprr
D. STREET ADDRESS 400 Pop dl BcMd..rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YES cV NO
3. A. AGE 38 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUp,L OCCUPATION Secutf\t M8aatger
B. TYPE OF INDUSTRY OR BUSINESS SMIS
5. PlACEOFBI1'l'l?t~*l".IIP
6. FATHER
A. NAME Cecil I nl5 CampbPll
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN, NAME 8IIy LorJIIM Jaoklon
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) CJlIt>IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Q8/ not / ..-~
, MONTH OAr vm-
D. ARE ANY FORMER' SPOUS'E(S) ALIVE? olES 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
0810111994 PoughIeepII~ Nt\t~ Vodc 0
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~:~~~~E)ClllApbeII
D. SOCIAL SECURITY NUMBER Q9D.-7&.D480
12. RESIDENCE A. tIMt:Y- B. ~'I
C. CHECK ONE 0 CITY cwrOWN 0 VILLAGE
AND 'AI- .
SPECIFY v-Wnger
D. STREET ADDRESS 1 Ed. Lane ZIP. 12590
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YES r:::vNO
,JR; / Vv 4fmJ
13. A. AGE 24
14. EMPLOYMENT
A. USUAL OCCUPATION LaIs ~DR M8aatgef
B. TYPE OF INDUSTRY OR BUSINESS SM"
15. PLACE OF BIRTH
16. FATHER
13.B. DATE OF BIRTH
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A. NAME Albeit Jasepb Callas
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME \A,.nll Lee Simkins
B. 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
000
B. HOW DID LAST IAARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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TIME MONTH YEAR MONTH YEAF
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SIGNATURE ~
DOH-98 (11198)
AM
M oe 08 11 01 2003
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL WY ~ - ,J~(
A. STATE NE ORK B. COU~3
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./'
o CITY OF 0 TOWN OF iJIo"'l1I'LLAGE OF
SPECIFY WAfJff:V~.e.S t:l;as
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