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STATE OF NEW YUH~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
(THIS SPACE FOR STATE U::;/: UNL.Y!
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FUll NAME
1 I......... 1 ~tnflrn
MIOOLtY- . CURRENT SURNAME
"mime '5 aie~eB.
FIRST MillflLE CURReNT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Fiedler
c. SURNAME AFTER MARRIAGE Stofko
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURllY NUMBER 099-6~ 1112
12. RESIDENCE A.~)YO~ B. Q~~5
C. CHECK ONE 0 CITY 0 ..oWN 0 VilLAGE
AND :w .
SPECIFY Appln~r
D. STREET ADDRESS 1 ""enry POfJd ZIP 17590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 29 13.B. DATE OF BIRTH MJIl / l\l
14. EMPLOYMENT .
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Bet,SflonS Scho'Ol District
15. PLACE OF BIRTH (~~~~.T~9.f*
16. FATHER
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT .
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) nRR-z;.6- 3360
D. SOCIAL SECURllY NUMBER
2. RESIDENCE A. ~wrt) Vnrk B. ~~P.~R
C. CHECK DINE 0 CITY DllItOWN 0 VILLAGE
AND W .
SPECIFY Appln~r
D. STREET ADDRESS 1 HAnry RnAd
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 39 3B. DATE OF BIRTH
4. EMPLOYMENT
YES 0 01/40
/~3
ZIP 1 ?lipn
o YES [JoI'No
....
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS Guy cmpemer Ii C9mpar:\Y
5. PLACEOFBIRTH I~M~.
6. FATHER
A. NAME JarniPl srt''J
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME DefGthy Wier
B. COUNTRY OF BIRTH U Sf .~
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
001
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 '!tATH
C. DATE LAST MARRIAGE ENDED? MONf}l Oy OAJm / ~poo
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES DoC>
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
0310412002 Mineels, New YeFk
o
o
o
A. NAME Michael Fiedler
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME MMshe Aekerm8ft.
B. couNmy OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 g g
B. HOW DID LAST MARRIAGE END? (3) 0 tlllJORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? or R4 / 'J"lJ2
MONTH OAf" YI!ilil'
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
21. SIGNATURE OF GROOM ~
DATE 05/01/.2003
by New York Domestic
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York person authorized
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the U
24. TOWN OR CITY CLERK
YEAR
~
{ SEAL }
'-t-'
NAME (PRINT)
05
08
20
01
06 2003
28. PLACE WHERE MARRIAGE OCCURRED
27. TYPE OF CEREMONY
A o~ RELIGIOUS 1 0 CIVil
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY D~A-t.Jb'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )( TOWN OF 0 VILLAGE OF
SPECIFY jJJ f b.J W (rJij) , 0 ~
"'" ~"" j.J? e., ""T
DATE -a.q () ~
I dG08
ON
STREET CITYfTOWN STATE
" WIT"" '" '~ .,,0
NAME (PRINT) ~, ~~
SIGNATURE ~ W
DOH-98 (11/98)
ZIP
". .'",,., '" ""'''!'~
"M",",""~~I I ~
SIGNATURE ~ J A. 7'-