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] COUNTY' OutdI.eM
CITYITOWN W~...
DISTRICT .._
NUMBER -1_
REGISTER ..
NUMBER ~
:::i I A I t: UF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ttPd H GiMB SURNAME
FIRST
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mismtle M. Ra~~URNAME
1. A. FUll NAME
11. A. FUll NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~ltM'Z~~~~~e~~SE) Gim-fIIt
D. SOCIAL SECURITY NUMBER 10Q.6&. 7828
12. RESIDENCE A. ~_) Vade B. ~eIIl
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND \.....
SPECIFY w_ppnger
D. STREET ADDRESS 179Wdmer Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~
13. A. AGE 38 13.B. DATE OF BIRTH MON'U / ~ / 'UI&
1Q0.64.3276
2. RESIDENCE A. _ Vade B. (~ElII
C. CHECK ONE 0 CITY 0 rIOWN 0 VILLAGE
AND
SPECIFY ,^""ppi~
D. STREET ADDRESS 179 Wdm., ~~
E. IS RESIDENCE WITHIN lIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 34 3B. DATE OF BIRTH
ZIP 12590
DYES o.f.lo
4. EMPLOYMENT
A. USUAL OCCUPATION Ca:d:nIdar
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5. PLACE OF BIRTH
6. FATHER
14. EMPLOYMENT
A. USUAL OCCUPATION Beautician
B. TYPE OF INDUSTRY OR BUSINESS ,..."... Of Flshklll
15.PLACEOFBIRTH (~IL~!York
16. FATHER
A. NAME Jatan RatiRlOR
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Phyllis 0em8th
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
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
o
o
o
....
S;
<C
Q 7. MOTHER
i!
U.
<C
A. NAME .... Gisllnd
B. COUNTRY OF BIRTH Gemllny
A. MAIDEN NAME JOIn !I'm
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
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
(2) 0 DEATH
YEAR
Iii
w
~
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that to
as to my right to enter into the marriage state.
..
o
o
o
21. SIGNATURE OF GROOM ~
o
o
o
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New York St named above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used onl se of a sBcond or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Domestic
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
MONTH
YEAR
AM
08
03
08
01 2003
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1"f. CIVIL
9 0 O:rHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY}..iC'Ila,5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF TOWN OF 0 VILLAGE OF
SPECIFY
()L(
s
NAME (PRINT)
SIGNATURE ~