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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1iI~ L ~NTSURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York bride and groom named above by any person authorized by New
Relations Law ~11 to perform marriage ceremonies w in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl
24. TOWN OR CITY CLERK
NAME (PRINT)
] COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutdu IS
'MIppInger
1_
70
1. A. FULL NAME
FIRST
a-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 126-72-1742
2. RESIDENCE A. ~.Yca:k B. (W~
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND
SPECIFY Uayd
D. STREET ADDRESS 652 Gregory Court
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 26 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH I-.....Ut.
6. FATHER
A. NAME JaIA8B .... IiIIII}IIh
B. COUNTRY OF BIRTH U 8 A
7. MOTHER
A. MAIDEN NAME Berbe,. Julienne Colangelo
B. COUNTRY OF BIRTH US,..
B. NUMBER OF THIS MARRIAGE 1
ZIP 12528
o YES O~
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....LL.
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
o
(2) 0 DEATH
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{ SEAL }
'-.,-I
SIGNATURE ~
MAILING ADDRESS
R
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A.. FULL NAME
Ji?IpI M. C....ENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. stt~~~~~~~e~~SE) liI~h
Ow SOCIAL SECURITY NUMBER 07s.. 7a.-7B12
12. RESIDENCE A. ~Yca:k B. tWm-
c. ~~CK ONE 0 CITY 0 i;1)WN 0 VILLAGE
SPECIFY LIayd
D. STREET ADDRESS 852 GNgoIy Court ZIP 12528
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0"fID
13. A. AGE 24 13.B. DATE OF BIRTH MO~ /3i /1;Qi9
14. EMPLOYMENT
A. USUAL OCCUPATION Ttlllding Ala_At
B. TYPE OF INDUSTRY OR BUSINESS VVappngenI CentniII SdIac
15. PLACE OF BIRTH 1~Mfl.&: Vork
16. FATHER
A. NAME Jam_ CDBta
B. COUNTRY OF BIRTH U 8 A
17. MOTHER
A. MAIDEN NAME CIen callbre.1
B. COUNTRY OF BIRTH USA
16. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 OEATH
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
22. SIGNATURE OF BRIDE ~
York Domestic
TIME
YEAR
AM
08
11
08 oe 2003
27. TYPE OF CEREMONY
O~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VIL';AGE OF
SPECIFY ~....'t Fc:'s- l-LWD
TITLE Fal/, ;/'.
DATE tilt. ~ O~
AI
ST TE
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH.96 (11/98)
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