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CITYITOWN ''N8ppInger
OIS'fAICT .. ~
NUMBER -4~
~~~~J~R 19
5T ATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~... M G~T SURNAME
A. FULL NAME
MloI~ 0 ~ENTSURNAME
FIRST
. 1 A.
FLU 'lAME
FIRST
Q.
N
8 BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
OPTIONAL. SEE ~EVERSE':
~ SOCIAL SECURITY 'lUMBER ~5911
gESIOENCE A ~ Yade 3. ,~
~ITY = TOWN = VILLAGE
Pnttghk~e
J ,TREE, -\0 DRESS 131 SWan ~ lit
C CHECK ONE
-\NO
SPECIFY
~)Yor.k
:hEC, ONE :::J ~ITY =
-\NO
S?=:.FY PnI'gh~<e
S-===- -\OORESS 131 SWan Colllt
12603
:IP
:::::p
12603
- S RESIDENCE WITHiN liMITS OF::TY OR iNCORPORATED VILLAGE' ...J YES =,,11;0
3. A AGE 'Zl 38. DATE OF BIRTH MONT11 / JP / vEUJl5 '3 -\. -\GE 31
4. E"1PLOYMENT /. '4. EMPLOYMENT
A. USUAL OCCUPATION Pali~ Ofticer A. uSUAL OCCUPATION Teacl1er
B. TYPE OF INDUSTRY OR BUSINESS Metro Nottb Police '3. TYoE OF INDUSTRY OR BUSINESS 'NaPPI CntJI. Soh. OIst.
I 5. PLACE OF BIRTH ,~_ HlJMrSAYort '5 PLACE OF BIRTH ,~ml~'m)I,J~I,.IMt~_
6 FATHER 16. FATHER
t- A. NAME Oar.iel Rid8:d Zebr
~ 8. COUNTRY OF BIRTH USA
c 7 MOTHER
u:
LL.
<
_. S ==SiOENCE WITHIN LIMITS OF CITY OR INCORPORATED VILL-IG='
- 'ES =~O
13.B. DATE OF BIRTH
/~Z2
\AO~ / Z2
A. NAME Peter S. Genaci
9. COUNTRY OF BIRTH USA
17, MOTHER
,0
Sussn elaine TOGI.
a ':;OUNTRY OF BIRTH USA
a ~UMBER OF THIS MARRIAGE 1
-\. MAIDEN NAME HelElemene Helge Behler
3.:0UNTRY OF BIRTH Qenn8ny
. 8. ~UM8ER OF THIS MARRIAGE 1
~gE\ ,Ol-S ,\\'ARRIAGES
-\ 'JL:MBER OF PREVIOUS MARRIAGES WHICH ENDED BY
:,"ORCE CIVIL -INNULME'JT
:E.:.;:.....
-\. MAIDEN NAME
9 ~REVIOUS MARRIAGES
-\. ~UMBER OF PREVIOUS '-lARRIAGES WHICH ENDED BY
JIVORCE :;VIL -\NNULMENT
DE.-\TH
o
o
o
o
o
o
3 ,ow :10 LAST MARR,AGe =,,0- ; _ :,'.C;::c::
3: ~-\NNL~~JE:'JT 2:.= :::.-\TC'
/ /
-.: ,', : : .;..s-:- \1ARAIAGE a..;o; } -= >. cqC=
:ATE --AST \MRR!AGE ='JDE:-
:-\-= _.-1ST \lARRIAGE ENDEC'o
'.1CN"~ JAY
J. -\RE ANY FORMER SPOUSE!S: -\UVE' = YES = NO
'0 F ~REVICUSLY ,1IVORCED ,:R .-\M'L.LED ~gCVIDE -HE "OLLCWING INFORMATiON
)A TE JF DECREE "_-\CESSLED -\GAINST NHOM
MONTH. JAY. YEAR' G,rY ::--\-E.CCUNTR~. F \OT USAI SELF SpeUSE
olEAR
,tc...-...... :.:..\
_. -\RE ,NY FORMER SPOUSE,S) ALIVE? = YES :::'.c
;: ::::2. C0SL Y JlvORCED OR ANNULEC. ::gC'VIOE -.:..,E -:.:..._::. \,G '\iF =n~"lA ;-.C~~
:::~-~ 2F JECREE ;JI....AC= SSL'ED ~G;'INS7 'NHC\~
'.le\' -- :AY "EARl CITY 3TATEC8V-,j:=?Y F ',CT ....S.~ .:c:...'-: .3PC:';SE
~ST
'ST
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1.21
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2ND
2~O
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3RD
4TH 4TM
I. being duly sworn, depose and say. that to the best of my knowledge and belief that the :nformatlon I provided is true and that: ceclar!! that noagal mpeClment eXists
as :0 my right to enter Into the marnage state. ~ \
SiGNA TURE OF "ROOM. 3: 5,'::1-;,,- _i"E:;F BRIDE ~ ~ ~ ~./.A j
- use CUAREN~AM
:3 SUBSCRIBED ANO'SWORN TO BEFORE ME
SIGNATURE OF TOWN CR CITY CLERK ~ DA,:: l17JnQ12OO3
This iicense authorizes the marriage In New York S authorized by ',aw 'IOrl<. Jomestlc
Relations Law 911 to oertorm marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY
= If checked. this license is to be used only for the purpose 01 a second or subsequent ceremony.
24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
i
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'en
Z
W
(J
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..-'-..
{ SEAL }
-.,-.
NAME PRiNT)
TIME
MONTH
YEAR
MONTH
YEAR
07
10
09
07 2003
STR
CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED 'BOVE ON -HE
DA TE 'ND -\ T THE riME ~ND
PLACE iNDICA TED
28, PLACE WHERE MARRIAGE':;C:;:.;RRED
A STATE NEW YORK 3 ::;_NT:/)u'-c..~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY .
= CITY OF = TOWN OF ~LAGE OF
SPECIFY WM/~6'f2,.S IItu.s