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COUNTY n, Jt~hp~~
CITYfTOWN \A'E:lrrinOpr
~~J~f~ 1368
~5~1~~R 8
:s I A It: UI- Nt:W YUHK.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D'iJild B. \Nhjt!~ENT SURNAME
~''''''I''' .....~ I.u...u~n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Q~{Jfla 1. COXCURRENT SURNAME
~
1. A. FULlNAME
11. A. FUll NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE \^'hitle"
(OPTIONAL - SEE REVERS!!'j . "1
D. SOCIAL SECURITY NUMBER 11 g 56 6755
12. RESIDENCE A. N v B. Ulc>tar
(STATE) ~)
C. CHECK ONE 0 CITY IiiI' TOWN 0 VILlAGE
AND
SPECIFY Lloyd
o. STREETADDREss19 Rnxallnfl Rlvd ZIP 1,?!=i?R
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES III NO
~H / ~ /of Q~~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 214 72 0302
2. RESIOENCE A. N ;tATE) B. q~~~)
C. CHECK ONE 0 CITY ~ TOWN 0 VILlAGE
ANO
SPECIFY Lloyd
D. STREET ADDRESS 19 Roxanne BI\ld ZIP 125/8
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE 46 3B. DATE OF BIRTH M~ / OJ / .;W56
4. EMPLOYMENT
A. USUAL OCCUPATION 06ver
B. TYPE OF INDUSTRY OR BUSINESS llirborne Express
5. PLACE OF BIRTH bl~~m~
6. FATHER
'A. NAME Arthur N. \^Jhitley
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rooatio A Sollman
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
13. A. AGE 39
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Office Manager
B. TYPE OF INDUSTRY OR BUSINESS Dr Schlam
15. PLACE OF BIRTH ~~,~u~'f Nl~lf
16. FATHER
A. NAME Albsrt M. Cox
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Elizabeth C. Elias:
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE" (3) 0 ANNULMENT
C: DATE LAST MARRIAGE ENDED? / /
DEATH
o
(2) 0 DEATH
100
B. HOW DID LAST MARRIAGE END? (3) Ii!l' DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / ":3 / "001
MONTH DAl ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? Iii!'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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1ST 11/13/2001 Of an go Co., Now Yorio(
2ND
3RD
4TH
I, being du y sworn, depose an
as to my right to enter into the m
21. SIGNATURE OF GROOt,4 ~
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23. SUBSCRIBED AND SWORN TO BEFORE 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.
011 checked, this license is to be used only for the urpose of a second or subse uent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
~
{ SEAL }
~
NAME (PRI
.......
TIME
YEAR
SIGNATURE ~
MAILING ADDRESS
AM
PM
02
04
2003 04
04 2003
A
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND SS .3 I () .
:~:::~:II::ED~' ~~'I r- $~M. ~~ 9 0 OTH:_SP:~: . . .t":__JJ.')tij C.
NAME (PRINT) l:;!.IV TITLE ~~-''''-''&J,
SIGNATURE ~ ' I,Lj rt 4f'.{flI'1-/ DATE t1)/JfX:# ~.Jt'ct3
D~E.,..te~~ A.. /1 '4m~ ~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY V;.Sl15Rj
1~ CIVIL
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J!!tTOWN OF
SPECIFY .J..LIJcf))
o VILLAGE OF
STATE
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11198)