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
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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
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(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
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
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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
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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
