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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ T. D' .~MNT SURNAME
COUNTY o-Ilcbess
CITYfTOWN \NappInger
~~~:~' 1368
~5~~J~R 111
1, A, FULL NAME
FIRST
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1Q3..68.-0059
2. RESIDENCE A. "lYar:k B. ~8IB
C. CHECK ONE 0 CITY ~OWN 0 VilLAGE
AND \A'"
SPECIFY v_pplagef
D. STREET ADDRESS 49 Hlmlet ~ lit ZIP
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A, AGE 35
4. EMPLOYMENT
3B. DATE OF BIRTH
M
A. USUAL OCCUPATION Detedive
B, TYPE OF INDUSTRY OR BUSINESS CIty Of PI,laldll
5. PLACEOFBIRTH~~~Yofk
6. FATHER
A. NAME I...oI.is SIIlv8afe D' 4JiIIo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME PMFICIII JNn Gherlrd
B. COUNTRY OF BIRTH U G A
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) c:JiIt>lVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? oe/ 15 / ..aaa
MONTH DA~ y-m-
D. ARE ANY FORMER SPOUSE(S) ALIVE? DIES 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 0W1511M ~ *'"1 York
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into th
21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~.. R. ~NT SURNAME
11. ^- FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, S~S~~N~~~~~~e~~SE)D' AliBe
0, SOCIAL SECURITY NUMBER Q&1__732~
12. RESIDENCE^- NI*1DFk B, ~BBB
C, CHECK ONE 0 CITY Qv1'OWN 0 VilLAGE
AND .
SPECIFY VVIIpplAg8I'
0, STREET ADDRESS 4e Hamlet Coult ZIP 12580
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Qf NO
MJJQ / 23 ~9BO
13. A. AGE 22
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Self - Employed
B. TYPE OF INDUSTRY OR BUSINESS Qraphlc DIIlgMI'
15, PLACE OF BIRTH I~Qlu'~ N...: York
16. FATHER
A. NAME Donald ElRK:8 Iickh8lt
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Diane Lee Smith
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 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
1ST 0 0
2ND 0 0
3RD 0 0
o 0
provided IS true and that I declare ~t no le,,1 im~ediment eXists
22 SIGNATURE OF BRIDE ~ J ~ ~
It- USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE DBI22I2OO3
This license authorizes.. the marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11 to perform marriage ceremonies within Ne ork State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl
24. TOWN OR CITY CLERK
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~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
25. B, SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
P
11:~~
08
23
10 21 2003
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TYPE OF CEREMONY
o p" RELIGIOUS
9 0 OTHER, SPECIFY
1 0 CIVil
28, PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUN~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF zJ VilLAGE OF
SPECIFY t'!6tJ ~ ~
TITLE ~
DATE 2.1. f(/f or 2.l'D 5
NAME (PRINT)
SIGNATURE ~
DOH,98 (11/98)
SATE
SIGNATURE