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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Arian H I antf~man
MIDDLE CURRENT SURNAME
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COUNTYnldr.hp.!,::!,::
CITYfTOWN Wappingp.f
~~J:~W 1 ').68
~5~I~J~R 1 n
1. A. FULL NAME
FIRST
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8. BIRTH NAME, IF. DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEb
D. SOCIAL SECURITY NUMBER' 90-50-5532
2. RESIDENCE A. Np.~AX)()rIc B. ~"
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND W .
SPECIFY applngp.f
D. STREET ADDRESS R Kre'ch Cjrcle ZIP 1 ?t;90
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YESt(] NO
& /1;!y /1ii7
3. A. AGEJS
4. EMPLOYMENT
A. USUAL OCCUPATION Controller
B. TYPE OF INDUSTRY OR BUSINESS Oeut~tt:t~ Bank
5. PLACE OF BIRTHP~ltStMs:~p ~~ Yor:k
6. FATHER
3B. DATE OF BIRTH
A. NAME Josepblandsman
B. COUNTRY OF BIRTH U $ A
7. MOTHER
A. MAIDEN NAME Marien Zelsberg
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
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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 FORMERSPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOULOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sflnnra.l Trar.v
MIDDLE 'CURRENT SURNAME
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JN~~b't~~O~~J~rmd~m an
D. SOCIAL SECURITY NUMBER 087 -68-21l4 7
12. RESIDENCE AN'A~rk B. n, ~~~
C. CHECK ONE 0 CITY @l TOWN 0 VILLAGE
AND W .
SPECIFY "Pplngp.r
D. STREET ADDRES.<6 Kfetci1 f':irc1e ZIP 17s!:m
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES.tI NO
13. A. AGE"S 13.B. DATE OF BIRTH oo_~.. """-fJ.:I
~ IIIIlmTH /~ DAY l-1lWAR
14. EMPLOYMENT
A. USUALOCCUPATIONH',man R~~ollrce~ Manager
B. TYPE OF INDUSTRY OR BUSINESS Advan~tar Communicationr
15. PLACE OF BIRTHD~a~tr.@_p '*~ Yort
16. FATHER
A. NAMEComeliu's Tracy
B. COUNTRY OF BIRTI{J $ 1\
17. MOTHER
A. MAIDEN NAME Adeline Ramus
B. COUNTRY OF BIRTtU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 0
B. HOW DID ~ MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANYFORMER 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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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Stat of the any person authorized by New Yo
Relations Law ~11 to perform marriage ceremonies within W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL}
'-v-'
NAME (PRINT)
29. OFFICIANT
NAME (PRINT)
STRE CION
30. WITNESS TO ~~EMONY
"'" ''''"" ~i t?ohUl
SIGNATURE~ ~
DOH-B8 (11198)
provided is true an
TIME
25.8. SOLEMNIZATION'PERIOD
ENDS AT MIDNIGHT ON:
MONTH
YEAR
MONTH
DAY
YEAR
AM
PM