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1. A. FULlNAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
,~B ~SURNAME
FIRST
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I"'JItlieia L ViII~T SURNAME
11. A. FUll NAME
FIRST
lL
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURllY NUMBER CJB8,.72>-95S3
2. RESIDENCE A. . VnrIr B. (~ElII
C. CHECK ONE 0 CITY QjltOWN 0 VILLAGE
AND '..1-
SPECIFY V....ppinr
D. STREET ADDRESS 4 ""'" View RoId
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~~~~~O~~SE) Ranallo
D. SOCIAL SECURllY NUMBER 074-7&-B948
12. RESIDENCE A. _IY-eFk B. Qutebess
C. ~~CK ONE 0 CITY 0 r7JWN 0 VILLAGE
SPECIFY V'.I8ppi....r
D. STREET ADDRESS 4 H \Aew R.EI ZIP 12598
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0.110
13.A. AGE 21 13.B. DATE OF BIRTH Mo4I / 12 /19&1
14. EMPLOYMENT
,A. USUAL OCCUPATION Un _ Ernplayed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Qwle..New.MorIt
16. FATHER
M
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 22 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION 8bift "Sailgel'
B. TYPE OF INDUSTRY OR BUSINESS .. :A111f1
5. PLACE OF IIIRTH . (~~;t'onc
6. FATHER
A. NAME R;cb8Ri Micha. R8Ralla
B. COUNTRY OF BIRTH USA
7. MOTHER
A. NAME Ja&eph A. Vi118ba1
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME ArteI.. Bell
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
DEATH
A. MAIDEN NAME (;10111 1. itA''''
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
o
o
(2) 0 DEATH
Goo
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o
o
o
o
o
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DATE
person authorized by New York Domestic
se of a second or subse uenl ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-'
25. B. SOLEMNIZATION'PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR MONTH DAY YEAR
AM
PM 08 11
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY u2.&pfV,,o('~ Ji.$t,
31. WITNESS
NAME (PRINT)
SIGNATURE ~