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COUNTY~
CITYfTOWN \IV8ppInger
DISTRICT1368
'. NUMBER
REGISTER 19
NUMBER
STATE OIfNEW YORK
DEPARTM~NT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Marlo Duprey
LI. .L!..
I STATE FilE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
leuJ tJ.!~
L [J SUPPLEMENTAL FILE ~
FRO~i~1Ramos
A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
0.
N
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEJ(Ii4-72_216U
o SOCIAL SECNITY NUMBER
2 RESIDENCE A. Y B DuIcheIa
(STjIIE) (COUNTY)
C CHECK ONi.. _ 1] CITY 0 TOWN 0 VILLAGE
~~~CIFY tJ88CGn
O. STREET ADDRESS 128 T<MnJlifdns Avenue
(STATE)'; (COUNTY)
C. CHECK Ollllia-..Li-~ 0 TOWN 0 VILLAGE
AND ~_
SPECIFY 4175th at. N. Ar;A. 223 58105
D. STREET ADDRESS l~
E IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATE'12LAGE? m 0
AGE 13.B. DATE OF BIRTH L::..
MONTH DAY
3. A.
12508
ll~
IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED tirGE? # YES ~914
AGE 18 3B. DATE OF BIRTH / /
MONTH DAY
13. A.
Y~O
YEAR
4 EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDU~Y~~I~2.q,. 7 ~ Germ.Iy
5. PLACE OF BIRTH ~
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER M8urIce R n.~
A. NAME 1JUtoI'IVJ'
B COUNTRY OF BIRTH USA
YEAR
14. EMPLOYMENT ~
A. USUAL OCCUPATION Y US........ F
u. ."" orc:e
B. TYPE OF INDUEJfOtIB..~,-4!ork
15. PLACE OF BIRTH ·
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER EdgIr Ramos
A. NAME USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME SylvIa Kruger
B. COUNTRY OF BIRTH Germ8iiY
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV06CE CIVIL AN~LMENT
17. MOTHER
Ruth D. IIem8ndIlz
USA
B. COUNTRY OF BIRTH 1
A. MAIDEN NAME
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'(jRCE CIVIL ANI)lLMENT
DEijH
DE(JH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
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1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the ma!r.~~ st te. (-'
&//;
21. SIGNATURE OF GR,9PM.
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA HIRE OF T jlVN OR CITY CLERK ~ DATE
This Iice'lse aut orrze~ the, marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
RelatiQns taw ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
' . OIl-checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CIT LE K 25. A. SOLEMNIZATION PERIOD BEGINS
o 0
o 0
o 0
o 0
nd that 1 declare that no legal impediment exists
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02:0:(~03
TIME
MONTH
YEAR
CITYITOWN STATE ZIP
27. TYPE OF CEREMONY
2B 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
29. OFFICIANT
NAME (PRINT) -,
SIGNATURE ~ .i
MAILING ADDR"l'S
TITLE
DATE
SPECIFY
STREET ,'" CITYfTOWN
30. WITNESS TO CEREMONY
STATE
liP
31. WITNESS TO CEREMONY
NM-.\E (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)