067
!z t-
w >
en
w <
III C
C
...J u:
;;)
0
:t U.
en <
z
0
~
0:
t;
c;
w
a:
w
Cl
<
if
0:
~
LL
0
~
u:
~
0:
W
0
W
0:
W 0:
~ W
CD
en ::E
en ;;)
w Z
0: 0
C ~
C
< t:;
~ W
C3 ~
w en
"-
en
W
U)
Z
W
(,)
::::i
C_J
~:i::z
;;)!::Q W
lii~~ t-
::ffiz <
~G~ (,)
::ECl5 u:
~Z: ~
~ 0 a:
~ ~ W
W c (,)
I- '"
o
z ~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
_de M. ~SURNAME
]
COUNTY Outcttns
CIlY/TOWN 'Napplnger
DISTRICT 1_
NUMBER
~5g~J~R ff1
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER Qll&.-4fi..5319
2. RESIDENCE A. __~ VB B. (~~I.I
C. ~BCK ONE ~ITY 0 TOWN 0 VilLAGE
SPECIFY PGlIghIaileplie
O. STREET ADDRESS 1 MIteheII Avenue
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
ZIP 12603
D.,tES 0 NO
3. A. AGE 39
4. EMPLOYMENT
A. USUAL OCCUPATION Milital)'
B. TYPE OF INDUSTRY OR BUSINESS URIecIStM Air F.orce
5. PLACE OF BIRTH (~".T__'" V.
6. FATHER
A. NAME Philip David UylBd
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME te.ae RoIIII. Setto
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
000
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, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
o
o
o
~
{ SEAL }
'-v-'
S
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 ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
~II A V'~ENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~~'Z~~~~~e~~SE) Mylac:I
D. SOCIAL SECURITY NUMBER oas-7Q..1259
12. RESIDENCE A. _IVark B. ~_I..
C. CHECK ONE . 0 CITY 0 rl/OWN 0 VILLAGE
AND \.J...
SPECIFY y._ppnger
D. STREET ADDRESS 39 Hamlet C'.oult
E.
ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES D~o
MOW / ~ /~
13. A. AGE Z1
14. EMPLOYMENT
A. USUAL OCCUPATION ClIliIR8 ~
B. TYPE OF INDUSTRY OR BUSINESS
13.B. DATE OF BIRTH
A. NAME ARlhDRy'I.HI
B. COUNTRY OF BIRTH U S .A
, ..
17. MOTHER
A. MAIDEN NAME Mery Ann Amltrano
B. COUNTRY OF BIRTH U S ^
18. NUMBER OF T~IS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
000
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
DATE
named above by any person authorized by New York Domestic
se of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
25. B. SOLEMNIZATION' PERIOD
ENDS AT MIDNIGHT ON:
MONTH
YEAR MONTH DAY YEAR
P
If. e. ;Jelf?-r
~/r1llo!J
,
08 08 08 04 2003
28. PLACE WHERE MARRIAGE OCCURR~ .
A. STATE NEW YORK B. couN~TC/fl;S;>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY W!1PI1I'1)6Ges r::irU.S
27. TY~OF CEREMONY
o B'RElIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
TITLE
NAME (PRINT)
SIGNATURE.
DOH-98 (11198)
I a.sc, ft)
ZIP
31. WITNESS T~~EMONY
NAME (PRINT) vrQ e L
SIGNATURE.