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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
l..cMeIl P. M~lcina 3rd
MIDDlE CU~RENT SURNAME
23. SUBSCRIBED AND SWORN l' BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the pu ose of a second or subse uent ceremon .
24. TOWN OR CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRI
-
COUNTY Dutchess
. C;T'YfTOWN WeDDlnaer
2~J:~W 1388
~5~~~R 95
1. A. FUll NAME
FIRST
Il.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE) ~ - ~8
D. SOCIAL SECURITY NUMBER uaa-'IC..~',
2. RESIDENCE A. NY B. n.~
(STATE) ~
. C. CHECK ONE 0 CITY ~OWN 0 VILlAGE
~CIFY E8It FIIhIcII
D. STREET ADDRESS 1 Peters Raed ZIP 12533
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIllAGE? 0 YES r!I NO
3. A. AGE 28 3B. DATE OF BIRTH ..Jl} / 11 / y1JIl5
4. EMPLOYMENT
A. USUAL OCCUPATION ~ng
B. TYPE OF INDUSTRY OR BUSINESS PrudenIIaI Flnsnc:lel
5. PLACEOFBIBTH ~~ .... ..
6. FATHER
A. NAME I..cMIII P. Mulldnl. Jr.
B. COUNTRY OF BIRTH USA
l-
s:
<C
C 7. MOTHER
ii:
II.
<C
A. MAlDEN NAME eM"""" Aivv*
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
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
(~~ri2$.c~) (CITY, STA~~~~F NOT USA) A~~SJpW~
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{ SEAL }
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I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~ H HslJir&RENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE. Mulleins
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 061.72-9876
12. RESIDENCE A. N(~ATE) B. ~~I.
C. CHECK ONE 0 CITY OIlltOWN 0 VILLAGE
~~CIFY -=... RIIhIdII
D. STREET ADDRESS SA t'.alllby Club DIWII ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES iY NO
13. A. AGE 29 13.B. DATE OF BIRTH ~ / ~ ",~
14. EMPLOYMENT
A. USUAL OCCUPATION T~
B. TYPE OF INDUSTRY OR BUSINESS
15. 'PLACE OF BIRTH ~ ~ ......... VOlt
~
18. FATHER
A. NAME Jahn 'Thnm_ ........
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME B8rbIra Anne AdImI
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTli DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
TIME
YEAR
DATE 07l2312OO3
11:00AM 07
PM
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND AM
~ :LA::~~:I~~;'"' ~ .' ~~7 ~~
~ ::::::~~ ~;:~ #4 ~
j:: MAILING ADD
a:
W STREET CITYfTOWN
o 30. WITNESS TO ~EMO~NY
NAME~J,~ ~ _&;~'iJ
SIGNATURE ~ -===-
DOH-98 (11198)
A
27. ry, OF CEREMONY
o uYRELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNn<'2)~-~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~t/CHKkR?.$ /..1(
TITLE eH#1?..{H.J
DATE 7 ~6 Ia..3
, /
STATE
NAME (PRINT)
SIGNATURE ~