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COUNTY Dutcl1 --
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~~~:~CJ 1388
~5~~J~R 88
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shane MiduNII Miller
MIDDLE CURRENT SURNAME
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennlf8r L R~dR
MIDDLE CURRENT SURNAME
1. A. FUll. NAME
11. A. FULL NAME
RRST
FIRST
a.
N
B. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MIler
(OPTIONAL - SEE REVERSE) __ ft.. ft 54
D. SOCIAL SECURITY NUMBER ~1
12. RESlOENCEA. ~..larlc B. ~
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND Fi=-a.un
SPECIFY ....HUII
D. STREET ADDRESS 1'- C Van Horn Qrcle ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!! NO
13. A. AGE 20 13.B. DATE OF BIRTH 11 /18 )[Qfr;y
----uoNTH DAY ~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(0PTI0NAl- SEE REVERSE) ..- - ~"14
D. SDCIALSECURITYNUMBER ~'-L'"
2. RESIDENCE A. Nf<<eYnrIr .B. ~...
C. CHECK ONE 0 CITY 'f!t TOWN 0 VILLAGE
~~IFY FIBhIdII
D. STREET ADDRESS 11 C V., Horn QrcIe ZIP 12508
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 22 3B.DATEOFBIRTH~
4. EMPLOYMENT
A. USUAL OCCUPATION YIiIIIIy
B. TYPE OF INDUSTRY OR BUSINESS MarIne Cor:ps
5. PLACE OF BIRTH CmII""*'" I Cl' ......
(CITY, ~Y IF NOT USA)
6. FATHER
A. NAME Dan Maff~~
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan G8v MIller
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
o
(2) 0 DEATH
14. EMPLOYMENT
A. USUAL OCCUPATION AhIfMnt
B. TYPE OF INDUSTRY OR BUSINESS C. I. A
15. PLACE OF BIRTH ~~F NOT USA)
16. FATHER
A. NAME C8mie I=I~ R~dB
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NM,lE Janet u. RobIson
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
o 0
DEATH
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B. HO\N DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DAle 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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
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(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
22. SIGNATURE OF BRIDE ~
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{ SEAL }
'-v-I
TIME
MONTH
YEAR
atlCf1l2lXYJ
AM
01:24PM at
I CERTIFY lHAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
o ~ RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Chr ~ p
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY LA k.\.~i-
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~