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J COUNTY. Dut~"
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1368
90
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
CITY {fOWN
'lJISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ja~ine M. M_~~RNAME
1. A. FULL NAME
~r J. ~RTSURNAME
FIRST
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~N~~~~~t~~e~~SE) 9padlilra
D. SOCIAL SECURITY NUMBER 134-.66-1737
12. RESIDENCE A. _lYO", B. ~8
C. gjgCK ONE 0 CITY 0 ijVWN 0 VILLAGE
SPECIFY PJeasam Valley
D STREET ADDRESS 132 North Avenue #1 01
.$I<
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 064_"7"\_964"7
D. SOCIAL SECURITY NUMBER --f---l-riE=--+
2. RESIDENCE A. IIJIIiIlII vo..a. B n. d,...-.
-(5IJllC) , WI. . (~
o CITY 0 "oWN 0 VILLAGE
Pleasant \/alley
D. STREET ADDRESS 132 North Avenue #1 01
ZIP 12589
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~o
MO~ / 013 /1;ii2
C. CHECK ONE
AND
SPECIFY
12569
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
/ /
MQND4 0~8 YE1,w
ZIP
31
13.B. DATE OF BIRTH
13. A. AGE
3. A. AGE
31
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Schaal Teacher
B. TYPE OF INDUSTRY OR BUSINESS Speckenlclll H. S.
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Pole. City Sell. DIst.
15. PLACE OF BIRTH (if~_IIX~A)
16. FATHER
A. NAME John MllIselli
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME LuClllle Eisele
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
DEATH
5. PLACE OF BIRTH
6. FATHER
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A. NAME Fnsnk M Splldara
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME URda M. Pelroe
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
o
o
o
o
(2) 0 DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH OA Y 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH OA Y 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into the mar
21.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
5 f my knowledge and belief that the in ormation I provided is true a d that
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23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CI CLE
This license authorizes t e m iage in New York State of the bride and groom named above by any person authorized
Relations Law ~llto perform marriage ceremonies within New ork State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W/161.2OO3
by New York Domestic
DATE
~
{ SEAL }
'-v-I
E
YEAR
NAME (PRINT)
SIGNATURE" -
MAILING ADDRESS
MONTH
MONTH
YEAR
TIME
07
17
09
14 2003
E
27. TYPE OF CEREMONY
o ~RELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURR~.
A. STATE NEW YORK B. COUNTY ..J}J.-L( ~S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY JCt/pI'1'V<; ~/{ <;
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
~..fiotc- "]),.c~~L-
~ ~5 6 ~
(\1 J2~q 0
TITLE
NAME (PRINT)
SIGNATURE ..
DOH-96 (1 1198)
NAME (PRINT)
SIGNATURE ..