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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tim....... " hviftd
MIDDLl-- ~ CUFlIft:NT SURNAME
o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
ie that the In ormation I provided IS true an that I declare that no egal impediment exists
22. IGNATURE OF BRIDE ~ /t!..,tJ.J J ~ AL.-' ~~.A J
"'1" USE CURRENT NAME"
DATE 0I8ID8I700..':t
by New York Domestic
23. ~~~~~=~Do~~~~~~Nci(f!~iJ~i~E.
This license authorizes the marriage in New York State of authorized
Relations Law ~11 to perform marr.iage ceremonies within New rk State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used ani ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
J
cour...y. ~~~,.J\'}
· CITYfTOWN VtIappI~
DISTRICT 1388
NUMBER
~5~~J~R 10$
1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
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2. RESIDENCE A'-bfM)Y~ B. ~
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND
SPECIFY ~.rrinf!r
D. STREET ADDRESS P 0 Rtw 1~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION ('..lVI'aI"finn ntfil'!tlr
B. TYPE OF INDUSTRY OABUSINESS ~J,w York 8tIte
5. PLACEOFBIRTH~oY.
6. FATHER
A. NAME limalby U.dia Irving
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME MlrlUllll &111I... .....
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
DEATH
o
ZIP 1~
o YES rYNO
o
o
B. HOW DID LAST MARRIAGE 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
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
a:
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{ SEAL }
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)
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PEA.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
03
I
26. SOLEMNIZATION OCCURRED
. 1M. AY
EAR
A
27. TYPE OF CEREMONY
r[1i( RELIGIOUS
9 0 OTHER, SPECIFY
s~~
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II.
~~~~ '" ~~k<<~
SIGNATURE ~ ' ~ rJ.
r'LlN~DRE ~ ~ \
.f>, )( 4~55' ~\ -Je-'t.
STREET ITYfTOWN
30. WITNESS TO C iEMOr V, i ()~l\i
TITLE 1'<.<'. P,e;.e:. ~.,.
DATE _%.( 1.t..} 0 3
N.1'
ATE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I<JIthMne A ChII
MIDDLE lm= SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF .DIFFERENT
C. SURNAME AFTER MARRIAGE Irvi'lg
(OPTIONAL. SEE RE~RSE1'M7.74-AI:AA
. 12. RESIDENCE A. ~Ernrlr B. ~
C. CHECK ONE 0 CITY LJillIItOWN 0 VILLAGE
AND ...L. .
SPECIFY "VIiIlPP"'-
D. STREET ADDRESS 47 CArmll DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [Ji NO
13. A. AGE 24 13.B. DATE OF BIRTH ~ / C1I -1~p
14. EMPLOYMENT
A. USUAL OCCUPATION T_r.h8r
B. TYPE OF INDUSTRY OR BUSINESS \Nepp. CAnf ~, rJI&t.
15. PLACE OF BIRTH U."hattlill\". w-., Vr.rlt
~HVir!l'cJi"Ut;;)
16. FATHER
A. NAME .1.,rqAlil C~A'-
B. COUNTRY OF BIRTH II 6 A
17. MOTHER
A. MAIDEN NAME Patltcll 0' Connor
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
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
TIME
MONTH
YEAR
MONTH
YEAR
IP
AM
02:57M
05 2003
08
07
10
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~lA..i~s~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF.=2( TOWN OF 0 VILLAGE OF
SPECIFY ~ o-.5T r: s-~ K:11 \
NAME (PRINT)
SIGNATURE ~