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COUNTY Dutdl!1S
. CITYf1"OWN Wlpplnger
DISTRICT 1_
NUMBER
~5~~J~R 101
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
..QmIid J. SeltMtENT SURNAME
o:Il"l~ r"1L.C nUMDl:n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
TaL MaI:Ih~ENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~SNt4~'l~~~~~e~~SE)Selber
D. SOCIAL SECURITY NUMBER CHI8 &4 6516
12. RESIDENCEA. NfM41aFk B. ~
C. CHECK ONE 0 CITY Or,IOWN 0 VilLAGE
AND
SPECIFY 'Nappinger
D. STREET ADDRESS 14& OIbome HII Road ZIP 12510
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0; NO
13. A. AGE 23 13.B. DATE OF BIRTH M. / 19 ~Q80
14. EMPLOYMENT
A. USUAL OCCUPATION NUI88
B. TYPE OF INDUSTRY OR.BUSINESS \-\4,,_ At ~eIC
15. PLACE OF BIRTH -p~Ntrf/ York
16. FATHER
A. NAME Samuel 8. Msllha.
B. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME Unde de I loose
B. COUNTRY OF BIRTH U S,\
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 116 64 7155
2 RESIDENCE A. ~M;VaFk B. ~8BB
C. ~~5CK ONE 0 CITY CiflTOWN 0 VilLAGE
SPECIFY 'Happinger
D. STREET ADDRESS 14& OSbome HII Road ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 22 3B. DATE OF BIRTH ~ / sa / vtQ81
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS NY S D. O. T
5. PLACE OFBlRTH ~,_obIIW 'tAt)
6. FATHER
A. NAME Edward SeIber
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cathleen L Reden
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
DEATH
DEATH
o
(2) 0 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
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MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUl-ED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE;JCOONTRY, IF NOT USA) SELF SPOUSE
o
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21. SIGNATURE OF GROOM ~
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23. ~::;,f~~~Do~Nfo~~06'~ J(iyBg~~i~E
This license authorizes the marriage in New York Stat
Relations Law ~11 to perform marriage ceremonies within
o If checked, this license is to
24. TOWN OR CITY CLERK
YEAR
MONTH
YEAR
DATE
of the bride and groom named above by any person authorized by New York
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
used only for the urpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
Domestic
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
TIME
MONTH
OB:2f(~
08
01
09 29 2003
IP
A E
27. TYPE OF CEREMONY
0;( RELIGIOUS
9 CI OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME M. DAY YEAR
/~"~.
1 0 CIVil
A. STATE NEW YORK B. COUNTY
"btVi2.M4
#oJ
03
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF)Cl VilLAGE OF
29. OFFICIANT
NAME (PRINT)
<I-
SPECIFY
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ZIP
". WIT'"'' ro:&
NAME (PRINT) ~
SIGNATURE ~
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