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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
S8mI Oygm
CURRENT SURNAME
COUNTY DutchU'
CITYI10WN1~
DISTRICT
NUMBER
REGISTER e8
NUMBER
1. A FULL NAME
MIDDLE
FIRST
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER
2. RESIDENCE A New YOlk
034-52-9393
Dutchesa
(COUNTY)
o VILLAGE
B.
(STATE) ~
C CHECK ONE 0 CITY LJ'""TOWN
AND \JUiarMoW_
SPECIFY ... -............
D STREET ADDRESS 7 C ~ Lane
ZIP 12580
DYES clNO
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A, AGE 43 3B, DATE OF BIRTH
4, EMPLOYMENT
A, USUAL OCCUPATION
JtrneIer
B TYPE OF INDUSTRY OR BUSINESS Self - ErndoYed
5, PLACE OF BIRTH MIdyeI, TlM'kIMI
(CITY, STATE/COUN;;".I~~T USA)
6. FATHER
A. NAME Orco ~
B. COUNTRY OF BIRT~
7, MOTHER
A, MAIDEN NAME F8IYd Ergam
B COUNTRY OF BIRTH TtHtcey
8. NUMBER OF THIS MARRIA~
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?
YEAR
MONTH DAY
0, 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
I
STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y) I
jU,LY tf/ c1tJrJ 3 Ncf a~&{)
6~b' 7ibtj
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Trici. M Rice
MIDDLE CURRENT SURNAME
~
11. A, FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT lJggFIn
C SURNAME AFTER MARRIAGE ()ygIm
(OPTIONAL - SEE REVERSE) ftDOJo..... .6"754
D. SOCIAL SECURITY NUMBER ~~
12 RESIDENCE A. New York B, I'lulr:h..-
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 tIoWN 0 VILLAGE
AND ~
SPECIFY DgI[
o STREET ADDRESS C ~. Lane ZIP
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13, A, AGE 34 13.B DATE OF BIRTH MO~ / W
1~
YES c::l'INo
A.
14, EMPLOYMENT
A, USUAL OCCUPATION A8III1='....A
B TYPE OF INDUSTRY OR BUSINESS T-~~M Re8Ity
15. PLACE OF BIRTH ~~..
16, FATHER
A. NAME MwIII_w J I V"
B COUNTRY OF BIRTH USA.
17. MOTHER
A. MAIDEN NAME Mary Ann ~
B COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DEATH
o
B HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? 08 / ?A / ..~
MONTH Dr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~S 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
~...~.. tllwYork
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1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, bemg duly sworn, depose and say. that to the best of my knowledge and belief that the mformalion I provided is t
as to my nght to enter mto the marria~ate.
21 SIGNATURE OF GROOM ~ ~ --; 22 SIGNATURE OF BRIDE ~
UlI'
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE 064J6I2003
This license authorizes the marriage in New YDrk and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies wit 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
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{ } NAME (PRINT)
SE~( f:ilMAf6Fit..
~MA~ S
~ STREET CI
I CH'lTIFY THAT I SOLEMNIZED 26, SOLEMNIZATION OCCURRED
TR1!\ ~ARF1Ii\GE OF THE PER-
$ONS .NA~O. .I\jlO.YE O. N THE TIME MO. DAY YEAR
mTE 'AND'-'I\t'li1E~T)~ ."'!'ID . AM
PLACIO INWCATEO' '.~.,' ' PM
S. 0 FF~I~"j,;,'I~.,..);;f\ I", i';~: ,
". . :I.-,',}-I.- j. 'e-- -'j.~ ',."
N.. AM.E (PR :p..,... '.'." ..,:.,~~....~.,
.~ . :"'.~r~ i'. .."
SIG~;t\j;QRE." ';-" ,.... . /,
MAILlf:'IG-'~ESS '.;:"".\\;
'. ,'.. e r'('~':'
STREET '- .
30. WITNESS TO CEREMONY
DATE
o
o
o
ent exists
TIME
MONTH
YEAR
MONTH
YEAR
nRIIIRt.XVn
AM
PM
05 2003
08
07
08
ZIP
12:
28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A, STATE NEW YORK B COUNTY
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
CITYITOWN
NAME (PRINT)
SIGNATURE ~
DOH,98 (11/98)
SPECIFY
STATE
ZIP
31, WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~