No preview available
084 STATE OF NEW YORK I STATE FILE NUMBER I (THIS SPACE FOR STATE USE ONLY) COUNTY o.tteh .- DEPARTMENT OF HEALTH CITY/TOWN ~nger DISTRICT AFFIDAVIT, LICENSE and NUMBER 1388 ~D~:~R 84 CERTIFICATE OF MARRIAGE Lo SUPPLEMENTAL FILE -.J FROM THE GROOM FROM THE BRIDE 1. A. FULL NAME ~ T Me IWNTSURNAME 11. A. FULL NAME ~u QI..... RRST FIRST I CURRENT SURNAME 0- N !z w m w III o .... ::> o :I: m ~ i Ii; a w a: w (!l .. ;;: a: .. ::; u.. o w !;( () iL ;:: a: w () w a: w ~ m m w a: o o .. it <3 w 0- m a: w III :! ::> z c ~ Iii w a: >- m j ~:i:z i=~g W :l;! ~ ~ ....c:( >-wz 3c3~ 0 ::;(!lB :':' !Z~m - ~~t i= itom a: 0>-" w wlllC3 0 5~"' z~~ 1ST 2ND 3RD 4TH I, being duly sworn, depose say, at to the best 0 my know as to my right to enter into the m~.~ 21. SIGNATURE OF GROOM ~ .J;'c! . USE CURRENT N E 23. SUBSCRIBED AND SWORN TO BEFORE ME 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 perlonn 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 U ose of a second or subse uent ceremony. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS ~ -~"~,,,~--""- '--"'-'---'-~"--' -~ B. BIRlH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE D. SOCIAL SECURllY NUMBER 2. RESIDENCE A. N(X'ATE) C. CHECK ONE 0 CITY iI TOWN AND SPECIFY fithIdII D. STREET ADDRESS 42 \f\tW1Itnn AYMH. ZIP. 1~" E. IS RESIDENCE WITHIN UMns OF cnv DR INCORPORATED VILLAGE? 0 YES '(fJ/ NO ~ /gj /WS B. ~1I11 o VIUAGE 3. A. AGE Xl 4. EMPLOYMENT A. USUAL OCCUPATION T~ B. TYPE OF INDUSTRY OR BUSINESS \Nepp C'*' SdVWlII 5. PLACEOFBIRTH~~YOflt 6. FATHER A. NAME EJIen!ft D-a~ ~ ft-, .Ir B. COUNTRY OF BIRTH II S A 7. MOTHER 3B. DATE OF BIRTH A. MAIDEN NAME ConAl May Illnc:lllsoA 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 DE.A TH o (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / MONl}t 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 w en z w o ::::i ~ { SEAL } '-y-I B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT __C~_S~S~JN~~~~~e~~s~C I~-~ D. SOCIAL SECURllY NUMBER 101..f31\..88R7 12. RESIDENCE A. N l:ATE) B. ~'r C. CHECK ONE 0 CITY [jfrOWN 0 VIUAGE AND SPECIFY ~... D. STREET ADDRESS 1".~ nrIv, . F ZIP 1~ E. IS RESIDENCE WITHIN LIMns OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO 13. A. AGE 28 13.B. DATE OF BIRTH ~H /28iv -1'~ 14. EMPLOYMENT A. USUAL OCCUPATION ~...........,.. B. TYPE OF INDUSTRY OR BUSINESS 'ftIA ~ 15. PLACE OF BIRTH ~JlMoYW 16. FATHER A. NAME [)nIV- Fnmk'llI.......,.. B. COUNTRY OF BIRTH U a A 17. MOTHER A. MAIDEN NAME LaII /tAR Mueller 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 (\ 0 DE.ATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH MONTH DAY 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 o o o o o o o o o o o DATE 07<<)1nnrR by New York Domestic TIME MONTH YE.AR WI011'.XVn AM 02:44PM at sm 1 CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. A 27. TYPE OF CEREMONY o ~ RELIGIOUS 9 0 OTHER, SPECIFY 10 CIVIL 28. PLACE WHERE MARRIAGE OCCURRED ';>Ui~ A. STATE NEW YORK B. COUNTY C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF ~ TOWN OF 0 VILLAGE OF au ~ 1)0e) eC~ SA!'\vc L mo/ISE ".lc S,'fc- av ~ SPECIFY