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COUNTY nllkhp!=;!=;
CITYfTOWN \M8ppinOPr
~~J:~cFi 1 ~1f)R
~5~~J~R 1 ')
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ins~nh I=' Cnrrl~rn
MIDIlLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~ ~4LJ<""J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~r~1 - K.:=tthprinF> RllrkF>
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE COrrlerO
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER nf\7 -f\R- ??n1
12. RESIDENCE A. N~~~A~)nrl< B. nl(!tr3~~~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fi~hl<i11
D. STREET ADDRESS 1308 Hopewell Avenue ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES!!'1 NO
Mg~H / ~ /of ~~~
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 053-70-4'327
2. RESIDENCE A. N v B. n. Itl"'h~<:::S
(S"fATE) ~)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY R~.:=tcon
D. STREET ADDRESS f\ pp.:=tn::;p PI;::t~p ZIP 1/508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
M~ / ~A~ / yl~83 13. A. AGE 18
13.B. DATE OF BIRTH
3. A. AGE 1 9
4. EMPLOYMENT
A. USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS II S Air I=nr~p
5. PLACE OF BIRTH 9!i~AT~~Rr,9~~ USA)
6. FATHER
3B. OATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION I Jnpmrlny~rl
B. TYPE OF INOUSTRY OR BUSINESS
15. PLACE OF BIRTH I=nrt P.F>nninn (;pnrni:=t
(CITY, STATElCOUNTRV'IF NOT USAF
16. FATHER
A. NAME . lamps Ed\^'ard Bllrkp
B. COUNTRY OF BIRTHII S A
17. MOTHER
A. MAIDEN NAME Bdlrbard Jean ,~,dam~
B. COUNTRY OF BIRTH U S 4-
18. NUMBER OF THIS MARRIAGE 1
lB. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
A. NAME A Ibert Cordero
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Nilsa l,I'/erado
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(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
C. DATE LAST MARRIAGE ENDED?
C. OATE 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
II:
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the infDrmation I provide is true and that 1 declare that nD legal impediment exists
as to my right to enter into the marriage tate.,;" ~1! '. c-t:2 _
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ I --!f:;AA ""(j- )<~~ rlN-U(
.. [( USE CURRENT NAME
23. DATE n?/11I?nn1
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)~a J. ~~~A
SEAL SIGNATU~ ~~~..J-fl ' tJl..-UtA-- DATE 02'13/')003
MAILING ADDRESS / .. . . -
'-.t-I ST~.g MiddlebLlsh~d, \^/appi~NFalls, NXATE12590 ZIP
~~~R~~~R;~~ IJO~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
YEAR
TIME
MONTH
AM
PM
02
14
2003 04
14 2003
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~~7C.JfsJ
D
C. LOCATION OF CEREMONY
(CHECK ONE AN':)PECIFY)
o CITY OF I!1TOWN OF 0 VILLAGE OF
SPECIF;:t:6~Ef~f.,.'t~, L
NAME (PRINT) ·
SIGNATURE ~l
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~
"