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J COUNTY
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STATE OF NEW YOHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
"'I""e L ~.NT SURNAME
ClTyrrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutdlll.
'Napt:ll....
1_
8i
1. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 091-12--8635
2. RESIDENCE A. ". YeFk B. (~81B
C. CHECK ONE 0 CITY 0 r/OWN 0 VILLAGE
AND
SPECIFY Paughk8eplie
D. STREET ADDRESS 6 Chlnnlngvlll. Ro8cI ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 rt/KJ
3. A. AGE 23 3B. DATE OF BIRTH Mool)1 / 0.42 / y!I1'
4. EMPLOYMENT
A. USUAL OCCUPATION M8GhaRic
B. TYPE OF INDUSTRY OR BUSINESS 5\,.".* Auto a.
5. PLACEOFilIRTH (~II~A)
6. FATHER
A. NAME Vinoent luGie P8BG8
B. COUNTRY OF BIRTH USA
...
~
Q 7. MOTHER
u::
LL.
<C
A. MAIDEN NAME UIHa" flit" YJlneer
B. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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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) SEUF SPOUSE
o
o
o
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ond .... \AIo.......t.
'fIIlffmr..~ M. ... .....'-ctJFm!NT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT MaRiJUIIRl
C. ~~~~~~t:~~~SE) flesee
D. SOCIAL SECURITY NUMBER CJ&2r~~..Q793
12. RESIDENCEA. ~.)YeFk B. ~81B
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND P uwh .
SPECIFY eLl... Jc8epB.e
D. STREET ADDRESS 6 CIl.AnI.ll. Road ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0./40
13. A. AGE 52 13.B. DATE OF BIRTH '...cJE / 2~ /1851
14. EMPLOYMENT
A. USUAL OCCUPATION SGhCHII SUB om...
B. TYPE OF INDUSTRY OR BUSINESS 'J/app. CnII. ~. DIst.
15. PLACE OF BIRTH (I-..rA~ t_~GFk
16. FATHER
A. NAME HaF81d 0tt8 MaRJIaFdt
B. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME DorIs Maybelle IIudIon
B. COUNTRY OF BIRTH USA
, "
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 _ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 11/ DA~1 / ylf88
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 Y/IS 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
11121.'1888 Peughleepsle, New VGFk 0 0 .;
o 0
o 0
DATE
bride and groom named above by any person authorized by New York Domestic
se of a second or subs uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-.,-I
NAME (PRINT)
TIME
MONTH
YEAR MONTH
YEAR
AM
09 28 2003
07
31
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAlIIEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
,
27. TYPE OF CEREMONY
D 0 RELIGIOUS 1 ~IVIL
9 0 OTHER, SPECIFY
NAME (PRINT)
SIGNATURE ..
DOH.9B (11198)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /)f.JrGIJ..&.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILLAGE OF
SPECIFY Id t/-P fJ / tJfJ-rzR,S ffl..t./...'9