116
ST ATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
J COUNTY -E).utehAM DEPARTMENT OF HEALTH
CI7rfrOWN w..pp~
~~J~~c;r 1368 AFFIDAVIT, LICENSE and
~~~~J~R 116 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME ~Rr B MlBLsURNAME 11. A. FULL NAME ~er L ~TSURNAME
FIRST FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 347-80-8701
2. RESIDENCEA. 'l~~J B. ~
C. CHECK ONE [j;CITY 0 TOWN 0 VILLAGE
AND
SPECIFY CftIllmbt..
D. STREET ADDRESS )43 OIAntA~ street
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
3. A. AGE 29 3B. DATE OF BIRTH
4. EMPLOYMENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~J~~~~~~O~~SE) '.NI1ItaA
D. SOCIAL SECURITY NUMBER 110.54-8391
12. RESIDENCE A. O~) B. ~~iR
C. CHECK ONE QjIIICITY 0 TOWN 0 VILLAGE
AND
SPECIFY Calumbl.
D. STREET ADDRESS 343 OJentangy Street ZIP 43202
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? o,tJyES 0 NO
MJ1l / OJ /1a1~
ZIP 432fO
OtI'iES 0 NO
13. A. AGE 29
14. EMPLOYMENT
A. USUAL OCCUPATION PrognIm Manllgel'
B. TYPE OF INDUSTRY OR BUSINESS Ohio State Unlver.
15. PLACE OF BIRTH~Yodc
. '" )
16. FATHER
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Rh~
B. TYPE OF INDUSTRY OR BUSINESS Ohio State Ilnlver
5. PLACE OF BIRTH ~~yarollna
6. FATHER
A. NAME Aiclulrd \NarrfH"a ~IIIU .r
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME 8emIcIeIt Slt_ DoIIR
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
A. NAME Gordan Alan WIIIton
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME MIFlI ARclelSOA
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
DEATH
o
(2) 0 DEATH
o
o
o
(2) 0 DEATH
B. HOW DID \.AST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
. . 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 0
2ND 0
3RD 0
~H 0
I, being duly sworn, depose and say, that to the best of my knowledge an
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
o 1ST 0 0
o ~ 0 0
o ~ 0 0
o 4TH 0 0
belie t at the Information I provided IS true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~. tD~
NT NAME
23. ~~N~~~~DC:N,.oO~06': ~~Bg~:i~E DATE nAlD?nnrn.
This license authorizes the marriage in New York St person authorized by New York 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING AD~RESS
YEAR
MONTH
YEAR
TIME
MONTH
AM
D2:2B'M
03
11
01 2003
09
ITY AE
26. SOLEMNIZATION OCCURRED 27. TYPyilF CEREMONY
1M M. DAY YEAR 0 ~L1GIOUS
~. ~3 9 0 OTHER, SPECIFY
REET
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. COUNT~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY W/llPl~S" M-us
10 CIVIL
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~