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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M._wT.S
MIDDLE CU SURNAME
] COUNTY Dutct\6$S
crtfrrowN WaDanaer
1388
73
DISTRICT
NUMBER
REGISTER
NUMBER
1. A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) D87 '7" '7~.
D. SOCIAL SECURITY NUMBER -I UO 1 o:JDI't
2. RESIDENCEA.~~ B.~k
C. CHECK ONE 0 CITY 0 -toWN 0 VILLAGE
~~CIFY Narwaad
D. STREET ADDR~ . Rlllf'OId Avenue ZIP Q2082
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? 0 YES D~
3. A. AGE 31 3B. DATE OF BIRTH 1n / m / 1Q7
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS Teractyne. Inc.
5. PLACE OF BIRTH ~RfElJSA)
6. FATHER
A. NAME
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c(
RabeIt BegJ
USA
B. COUNTRY OF BIRTH
7. MOTHER
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
NAnqt JuMl-.
USA
1
DEATH
o
B. HOW DID LAST MAmlIAGE'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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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{ SEAL }
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarah E. Burnett
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME.(MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE) ft'7ft ~ -.
D. SOCIAL SECURITY NUMBER UI ~=:JDoDI3Q
12. RESIDENCE A. .)Vark B.~
C. CHECK ONE 0 CITY 0 ~WN 0 VILlAGE
AND ........
SPECIFY VDIlPPoger
D. STREET ADDRESS 5Q2 Po.puIa Boulevard ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 ~
13. A. AGE?R 13.B. DATE OF BIRTH MJ'j) / Dl~ / ~?l5
14. EMPLOYMENT
A. USUAL OCCUPATION TeIICher
B. TYPE OF INDUSTRY OR BUSINESS Wapplngers Schaal rlstrId
15. PLACE OF BIRTH Platlsbumh, New York
(CITY. STATElCOU~ IF NOT USA)
16. FATHER
A. NAME ~ Burnell
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Beare Slezak
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
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
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
o
o
DATE 06f1612C1J3
person authorized by New York Domestic
TIME
YEAR
AM
03:CJ7M
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
o II RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11198)
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" -U-t>?j
/V.l-:
STATE
A. STATE NEW YORK. B. COUNTY W ilt"I-"OIM
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY
i.J 0.. ff~
Ge6l"'lfe.-
NAME (PRINT)
SIGNATURE ~