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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
WlliJIIII T .1nhnIInn
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ON/.-Y)
L 0 SUPPLEMENTAL FILE
~
FIRST
FROM THE BRIDE
11. A. FULLNAME FIRST .gp M. De ~SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Maltini
c. S~~J~~~~~~~~SE) ..JahnBaR
D. SOCIAL SECURITY NUMBER CJS2..46..8]Q7
12. RESIDENCE A. t!Il1Rr) Yar:Ic B. ~..
C. ~5CK ONE D CITY D fl/)WN D VILLAGE
SPECIFY VVIIppinger
D. STREET ADDRESS 30 Kendell DrIve ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? D YES D ~
13. A. AGE 49 13.B. DATE OF BIRTH ~ / 2a / UI53
14. EMPLOYMENIT
A. USUAL OCCUPATION Clims MaRager
B. TYPE OF INDUSTRY OR BUSINESS Clrecor. NIIontII
15. PLACE OF BIRTH~I~)
16. FATHER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) .
D. SOCIAL SECURITY NUMBER ~EAA~
2. RESIDENCE A. _Vnrtr B.~
C. CHECK ONE D CITY D I/IoWN D VILLAGE
AND .......
SPECIFY VVBIPP~
D. STREET ADDRESS 30 Kend8l1 DrIve
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 40. 3B. DATE OF BIRTH
ZIP 1~
D YES D.tlo
4. EMPLOYMENIT
A. USUAL OCCUPATION Ua"9" nr I T
B. TYPE OF INDUSTRY OR BUSINESS CaflCOf. Ndonll
5. PLACE OF BIRTH Uftllllllllllllllft I hh
(~SA)
6. FATHER
I- A. NAME WII,.m Rayd I~
:;: B. COUNTRY OF BIRTH USA
c(
Q 7. MOTHER
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c(
A. NAME AnItIany MaltiRi
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME oenevtwe RIPP6
B. COUNTRY OF BIRTH U &; ^
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
. DEATH
Ell. HIli
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 4
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
'2 1
B. HOW DID LAST MARRIAGE END? (3) D ~ORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? W 30 / ~
MONTH DAY Y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~ D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
'1MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0512&11982 GosbeD. ~Iiw: Vork
~~.~Yodr
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) D -"'ORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? W "'2 / 'Vtt'II'I
MONTH DAY' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D liII!s D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNlTRY, IF NOT USA) SELF SPOUSE
o
1
04I12.QQQO DuWu II County, N V
D., D
D D
D D
D D
gal i~pediment eXists
22. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit n New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used onl urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
25. B. SOLEMNIZATION'PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-I
YEAR
MONTH
DAY
YEAR
TIME
MONlTH
SIGNATURE ~
MAILING ADDRESS
08
19 2003
08
21
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
A 0 ~ RELIGIOUS 1 D CIVIL
o 3 9 D. OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ql TOWN OF D VilLAGE OF
SPECIFY 2AI't ?'<h"--ll
mu Q lr\~
DATE !IJ I;>. f 03
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