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~TA I ~ UI- N~W YURK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tl!E8Il( BorRDENT SURNAME
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
edge and belief that the information I provided is true and that I declare that no legal impediment exists
~~-L-J7Jt.~
USE CURRENT ~ME
DATE _
This license authorizes the marriage in New York State 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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutctusr
CITYITOWN VVeppinger
~~J:~~T 1368
~5~~J~R 76
1. A. FULL NAME
FIRST
'o)1"'1~ F'"ILC, nUMDJ:tI
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
SIRAn U I ~
MIDDLE ~RRENT SURNAME
..J
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 ~ 72..9876
2. RESIDENCE A. N ;tATE) B. ~
C. CHECK ONE 0 CITY fiI TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 4 ~J'AhI t'..."lIrt ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t'I NO
M~~ /=\1 /'115
3. A. AGE 2B
4. EMPLOYMENT
A. USUAL OCCUPATION 1""'81"
B. TYPE OF INDUSTRY OR BUSINESS llme werner Cable
5. PLACE OF BIRTH ~A-"RX.USA)
6. FATHER
A. NAME Tbamas J Bonelli
B. COUNTRY OF BIRTH II S A
7. MOTHER
3B. DATE OF BIRTH
A. MAIDEN NAME Roxanne 80era
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
DEATH
a
(2) 0 DEATH
11. A. FULL NAME'
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~N~rz~~~t~~e~~S~i
D. SOCIAL SECURITY NUMBER 084-7a.1 ~
12. RESIDENCE A. N l'TATE) B. ~~
C. CHECK ONE 0 CITY rJl'TOWN 0 VILLAGE
AND 0.... uooha..-i
SPECIFY ---Y--~V-e
D. STREETADDREss22.SAnd DrIve ZIP 12803
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13.B. DATE OF BIRTH -JlH /1~iv .191J-
13. A. AGE 28
14. EMPLOYMENT
A. USUAL OCCUPATION ~ I;d T88Cher
B. TYPE OF INDUSTRY OR BUSINESS Sl Fl'8nds ~
15. PLACE OF BIRTH ~!'N~Yorlc
16. FATHER
A. NAME ~lnhn K I ftr\G. Sr
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME P8tr1da A. Smith
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
a a
DEATH
o
o
o
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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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B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE 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, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the ma
21. SIGNATURE OF GROOM ~
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en
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,-A-.,
{ SEAL }
'-v-"
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
YEAR
DATE 0RI1Q12OD3
11:22AM 06
PM
ZIP
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SATE
27. TYP~CEREMONY
o ~L1GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;;J)~.s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY WIIPf'/~~S [:'I'-f(.(.,S
,e. e. fklEs-r
~ .:l~ ;)ft3
f" .:2590
STATE
31. WITNESS TO
NAME (PRINT)
SIGNATURE ~