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COUNTY nlJtchess
CITYfTOWN IN;=trrinaer
~~J~~CrJ 11flR
~5~I~J~R ':I,
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
CaMilli's A Pel',so
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
M~t:~'y Cohpn CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~M..~~~~t~~e~~SEfelllso
D. SOCIAL SECURITY NUMBER 115-6?-1483
12. RESIDENCE A. N J'rATEI B D!d!!f,Pv~~~
C. CHECK ONE 0 CITY WTOWN 0 VILLAGE
AND IN .
SPECIFY '1pptnopr
D. STREET ADDRESS 510 Maloney Road Apt H ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:!' NO
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 097 -68- ? 803
2. RESIDENCE A. NIX-TEl B. Qb~E'S5
C. CHECK ONE 0 CITY [g TOWN 0 VILLAGE
AND 1M '
SPECIFY U \l ::1pr1f"\ger
D STREET ADDRESS 51() Maloney Road Apt H
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE?
3. A. AGE 33 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Bindery Operator
B. TYPE OF INDUSTRY OR BUSINESS SOl ,th("rn n, It~"e9S f\lpws
5. PLACE OF BIRTH ~~~~5lfJrR.lJ~~ uY.~?rk
6. FATHER
13.B. DATE OF BIRTH
ZIP 1 ?R()3
DYESMNO
13. A. AGE 2'1
14. EMPLOYMENT
A. USUAL OCCUPATION Salee; RepresiOntative
B. TYPE OF INDUSTRY OR BUSINESS ~t1Ilthprn n, It~hp~~ Npw~
15. PLACE OF BIRTH ~OI~rmM3~~Ryt;Je~uXrrk
16. FATHER
A. NAME Philip Pelllso
B. COUNTRY OF BIRTH " S A
7. MOTHER
A. MAIDEN NAME Elizabeth Mahoney
B. COUNTRY OF BIRTH U S f:.
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Ted CohE'n
B. COUNTRY OF BIRTH I I ~ A
17. MOTHER
A. MAIDEN NAME Leona '1ogt
B. COUNTRY OF BIRTH , I S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
DEATH
n
(2) 0 DEATH
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n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
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1ST 0 0 1ST
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 a
as to my right to enter into the marria estate..
21. SIGNATURE OF GROOM ~
o 0
o 0
o 0
o 0
that I declare that no legal impediment exists
~
USE CURRENT NAME
DATE n1/171?On1
by New York Domestic
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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.
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
t-"-.
{ SEAL }
'-v-I
NAME (PFl!!:!!
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
YEAR
MONTH
YEAR
AM
12:22PM
01
18
200
03
18 2003
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ZIP
1~IL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY \ .t) 0 )0 ~~ ~e ~
V I ->
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~