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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Hcntio Frederick Widman
MIDDLE CURRENT SURNAME
COUNTY ~
CITYITOWN WapDInaer
DISTRICT 1~
NUMBER -JIIN
~5~lgJ~R 74
L A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) "Dft_~_a349
D. SOCIAL SECURITY NUMBER \AJ\l"OAr'U
2. RESIDENCE A. 0 C B. WBshinatan
(STATE) (COUNTY)
C. CHECK ONE [jlI'CITY 0 TOWN 0 VILLAGE
AND "A_~....._
SPECIFY VV_RIJYIUII
D. STREET ADDRESS 2700 Q street N W #310 ZIP 2<<XJ7
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 ~ES 0 NO
3. A. AGE 28 3B.DATE OF BIRTH 05 / 14 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION PhvBician
B. TYPE OF INDUSTRY OR BUSINESS GeorlI! Washington
5. PLACE OF BIRTH ~~NeWVork
~EiCOij~F NOT USA)
6. FATHER
A. NAME Horatio Sevmour Widman
B. COUNTRY OF BIRTH Mexico
7. MOTHER
AnnA "ArI. FlAnnAIY
USA
1
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID 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
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
o
o
o
w
UJ
Z
W
o
:J
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH-9B (11198)
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Karen Gordon
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE GaIdon Widman
(OPTIONAL. SEE REVERSE) 091~' ~
D. SOCIAL SECURITY NUMBER ., couauu
12. RESIDENCE A. 0 C B. Washington
(STATELo (COUNTY)
C. CHECK ONE 0 ~ITY 0 TOWN 0 VILLAGE
~~CIFY Washington
D. STREET ADDRESS 21OI:fC Street N W #310 ZIP 2OD07
E. IS RESIDENCE WITHIN UMrrs OF CITY OR INCORPORATED VILLAGE? O~ES 0 NO
13. A. AGE L/ 13.B. DATE OF BIRTH 10 / 28 /1975
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Physician
B. TYPE OF INDUSTRY OR BUSINESS ~ UniversItY
15. PLACE OF BIRTH Mlnhltten. New ork
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Jack Gordon
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME ~"'nne P8I8tnlk
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) o 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
o 0
o 0
o 0
o 0
at no legal impediment eXists
22. SIGNATURE OF BRIDE ~
06f1712OO3
DATE
named above by any person authorized by New York Domestic
U ose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME MONTH
YEAR
08
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY!! U;; "It:R
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF. TOWN OF 0 VILLAGE OF
',-'i3 't>v."~ofl~ f\,-,-o~b
SPECIFY .,...,
rvt; YV 'l 0 (~~ I "2....lrO ~