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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~m I. Kh@IIENTSURNAME
COUNTY Dutch II 55
CITYrrOWN \Napt:ingel'
~~J~fri 1368
~5~I~J~R 56
1. A. FULL NAME
FIRST
0.
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURllY NUMBER Q6&.7&Q273
2. RESIDENCE A. N ~ATEI B. ~I II
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
ANa n-.UIIh~
SPECIFY r-U1~tt
D. STREET ADDRESS 44 Old Ferms Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ill NO
3. A. AGE 33 3B. DATE OF BIRTH M~ / ~. /111Q
4. EMPLOYMENT
A. USUAL OCCUPATION Deli OWner
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH I~~ IF NOT USA)
6. FATHER
A. NAME .... KbIIIiI
B. COUNTRY OF BIRTH Jorden
7. MOTHER
A. MAIDEN NAME HudI F8kheuIy
B. COUNTRY OF BIRTH JoIdIn
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
ArM8 NIIIMIiwI@tRENTSURNAME
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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
11. A. FULL NAME
FIRST
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~S~J~~~~~e~~sp.lil
D. SOCIALSECURllY NUM8ER 592-4C)..8898
12. RESIDENCE A. N '(TATE) B. ~~ ~II
c. ZJ~CK ONE 0 CITY Iijl'TOWN 0 VILLAGE
SPECIFY E8II: FISbIdI
D. STREET ADDRESS 10.Geneva Ddve ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES @ NO
.H /Q3AY 19B
13. A. AGE 19
14. EMPLOYMENT
A. USUAL OCCUPATION Btudeal
B. TYPE OF INDUSTRY OR BUSINESS Dutch I S S CGmm. Colt
15. PLACE OF BIRTH ~~_FY_)
16. FATHER
A. NAME Mcxir ~..beiwIIt
B. COUNTRY OF BIRTHJordIn
17. MOTHER
A. MAIDEN NAME .~ Neshell:JIIt
B. COUNTRY OF BIRTHJ0rd8n
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
13.B. DATE OF BIRTH
DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the Information I provided IS true a
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23. SUBSCRIBED AND SWORN TO BEFO ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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 ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM"
~
{ SEAL}
'-.,-I
NAME (PRINT)
DATE 05ID7Q0D3
by New York Domestic
TIME
MONTH
YEAR
ZIP
AM
PM
08
07
06 2003
05
8T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TA
27. TYPE OF CEREMONY
aX RELIGIOUS
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
3:00
(0
03
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
1:> u +ch~5 s
ZIP
31. WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
.b(CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Povtl ~ /Cee/p~
Sf. dfJ,'mes i/ or~o~ X. C~.JreL
29 OFFICIANT 1J' h ~ I . .
NAME (PRINT) I=I'IT"hv-. n/S a"Y7 A//;.4I{,
SIGNATURE" F,. p~ ~~.
MAILING ADDRESS
17f? 5P~I<e-n k,'/I ~. PtJ{)~/'~e;',de
STREET . CITYrrOWN (.,
3D. WITNESS TO CEREMONY
TITLE t>riehY-
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,
A-IY /,;!. 603
STATE'
DATE
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~