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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~Jd KalliltlRRENT SURNAME
o 1ST 0 0
o ~D 0 0
o 3RD 0 0
o 4TH 0 0
Ie t at t e ormation provl IS true and that eclare t at no lega Impediment eXists
22. SIGNATURE OF BRIO;. ~ (V\ ~ n O,^{
, USE CURRENT~
DATE nRI3OQOO3
This license authorizes the marriage in New York Sta e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the U ose of a second or subs uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY cutchlll
CITY/TOWN \NIIpplnger:
DISTRICT
NUMeER ~_
REGISTER 82
NUMBER
1. A. FULL NAME
FIRST
11.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER G87 -.54-31'21
2. RESIOENCE^,. N ~ B. ~.
( ATE)
C. ~~CI( ONE 0 CITY iii TOWN 0 VIlLAGE
SPECIFYFilIIIcI
D. STREET ADDRESS 14 G Fem Court
"
1,i6~1f-
ZIP j2886
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE? 0 YES '" NO
M /~ /1810
3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION TRXIp8I'
B. TYPE OF INDUSTRY OR BUSINESS Ny.... PdIce
5. PlACE OF BIBnI ~..MIWy-
6. FATHER
A. NAME QenIIc:I KalIl.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME l<8ltlleen PtwIenIs
B. COUNTRY OF BIRTH U' A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3B. DATE OF BIRTH
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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{ SEAL }
'-..,-I
DATE 06130I2OO3
AM
PM
rtI
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FUU NAME
QIt\!R M. MIII!URRENT SURNAME
FIRST
B. BIRTH NAME (MAlOEN NAME), IF OIFFERENT
C. SURNAME AFTER MARRIAGE -<ssiI1.
(OPTIONAL - SEE REVERSi!j"
D. SOCIAL SECURITY NUMBER G77-7Q..11J12
12. RESIDENCE A. N YTATE) B. ~
C. 2)jI5CKONE 0 CITY ~TOWN 0 VIlLAGE
SPECIFY La G)..
D. STREET ADORESS ~ Ovedook Roecl AIt. 2 ZIP 12803
E. IS RESIOENCE WITHIN UMITS OF CITY OR INCORPORATED VIllAGE? . 0 YES II NO
13. A. AGE 33 13.B. DATE OF BIRTH dliH /2Rv __
14. EMPLOYMENT
A. USUAL OCCUPATION T~
B. TYPE OF INDUSTRY OR BUSINESS N y ~ PolIce
15. PLACE OF BIRTH 11-. MlWX-
16. F~THER
A. NAME Jahn Mall
B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME 98.... BnHIey
B. COUNTRY OF BIRTHU . A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
o
o
B. HOW OlD lAST MARRIAGE ENO? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAV
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, DAv, YEAR) (CITY. STATE/COUNTRV, IF NOT USA) SELF SPOUSE
o
(2) 0 DEATH
VEAR
TIME
MONTH
YEAR
I CERTIFY THAT I SOlEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
0]
27. TYPE OF CEREMONY
o r;:I. RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
TITLE --f(. (!, - ,t" "'y.+
DATE 7 /;~/dJl
I /
}I ) 2(33
STA ZIP
31. WITNESS TO CER 0 Y
26. SOLEMNIZATION OCCURRED
M M Y
'~n> 07 1<.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY E a-.s1- hShk:l)
NAME (PRINT)
SIGNATURE ~
'-