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] COUNTY putehA~
CITYIT~WN ~9"
, DISTRICT ,,~
NUMBER .t~
~5~lgJ~R 91
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~R O'~E
r-
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~BlIr
MIIMlE- _.P .~RRENT SURNAME
1. A. FULL NAME
,11..A. FUll NAME
FIRST
RRST
l1.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE O' GannaII
(OPTIONAl. SEE REVERSE)
D. SOCiAl SECURITY NUMBER 123-4008367
12. RESIDENCE A.__lYark' B. ~eaf"
C. CHECK ONE 0 CITY 0 IIJbWN 0 VilLAGE
AND .&.1-.
SPECIFY ..-pp..-
D. STREETADDRESS M D ~rhNw'gh LAnA ZIP 1~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES D..4lo
13. A. AGE -45 13.B. DATE OF BIRTH A / l' /1W
14. EMPLOYMENT
A. USUAl OCCUPATION [)dyer Instructor
B. TYPE OF INDUSTRY OR BUSINESS Dt deb_ SCJ'uW 01 DJlvInt
15. PLACE OF BIRTH (~~MMoY.
16. FATHER
A. NAME Stanley 9NvII
B. COUNTRY OF BIRTH II 8 A
17. MOTHER
A. MAIDEN NAME s.IV KYler
B. COUNTRY OF BIRTH USA
16. 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 Il1'IORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12/ tf.7 / ~
MONTH DAY' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 1fs 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
12117/J002 Pough..... ..1ft' York 0
o
o
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
1 Q9.52.71 01
2. RESIDENCE A. _v. B. (~t'.1
C. CHECK ONE 0 CITY D-'OWN 0 VILLAGE
AND
SPECIFY \lVstppiT"
D. STREET ADDRESS M D ~9' I AnA
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE -45 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Shop RIte
5. PLACEOF"BIRTFI (~~y.
6. FATHER
A. NAME Ricbel"fl MIItbrHt O' GeJrnI.n
B. COUNTRY OF BIRTH II S A
7. MOTHER
ZIP ..~
DYES 0.440
EI....lhomlll". MaI~
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D.ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? at'" ~ / tf.,..a
MONIli DAY-- ~
D. ARE ANY FORMER SPOUSE(S) AliVE? 0 ~S 0 NO
10. 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
O8t.28I1_~.Ne\~York 0
o
o
A. MAIDEN NAME
DEATH
o
DATE lfll17nrYn
by New York Domestic
w
U)
z ~
~ {SEAL}
'-v-I
TIME
NK)NTH YEAR
09:~ 07
18
09 152003
1 ""L
2B. PLACE WHERE MARRIAGE OCCUR~ _
A. STATE NEW YORK B. cou~1fUl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ~ILLA~ J/~
PECIFY~I~~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
OOH-9ll (11198)
NAME (PRINT)
SIGNATURE ~ ·