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COUNT'lQLlk'I:r.:>~s:
CITY fTOwr:i,fV :J ;l[-' i "1":1'::' ,.
DISTRIC"1 r ",." ~
NUMBER .:ltltJ
~G~I~J~R1 92
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
fl PI" ""'"I qtn 1\,,/18
, " MioO[~ "'. - .1 '-' , CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1 A. FULL NAME
11. A. FULL NAME
FIRST
Hr~'I;~'n r: PI:::md<
MIDDLE CURRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTM eSlgl-lr->r
C. SURNAME AFTER MARRIAGEP!'an"'K - Sin I\I\IP
(OPTIONAL. SEE REVER,;E . . r
D SOCIAL SECURITY NUMBER 1 r, 1- 36-901-\ ,
12. RESIDENCE 4\\ ''((STATE) Brlll~~~~~
C. CHECK ONE 0 CITY <iJ TOWN 0 VILLAGE
AND _\ I .
SPECIt"Yl^ appll1QPr
D STREET ADDRES~~ J~ew Hackensack Rd ZIP17590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES>otJ NO
13. A. AGE56 13,B. DATE OF BIRTH Q&TH /1 ~AY /?y~R
14. EMPLOYMENT
A. USUAL OCCUPATI0Nt10m"'rnakor
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTiBp?lf':r.f) ~\P\kI \{ r.rl<
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAM~/Villiam B Meagh"'r
B. COUNTRY OF BIRT~ I R A
17. MOTHER
A. MAIDEN NAMEHelen Rodak
B. COUNTRY OF BIRTI\U S A
lB. NUMBER OF THIS MARRIAGE ')
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
0-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 131
2 RESIDENCE AN '(STATE)
C. CHECK ONE 0 CITY;,iO TOWN
AND
SPECIFY VVeq::ping@r
D STREET ADDRESs95 New Har'l<er'Sar:1< Rrl ZIP 125qn
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEMJ NO
3 A. AG~9 3B, DATE OF BIRTH ~H / CQy / ~~;3
4. EMPLOYMENT
~ 8 1862
BD~~';;c;;
o VILLAGE
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A. USUAL OCCUPATION Funeral Director
B. TYPE OF INDUSTRY OR BUSINESsMi"'hael I Higgin<:: FII!1r->ral
5. PLACE OF BIRTtB\t9P~TA~J.alMnW~T USA)
6. FATHER
A. NAME Hov/ard Struwe
B. COUNTRY OF BIRTHU SA
7. MOTHER
A. MAIDEN NAME Julio Miller
B. COUNTRY OF BIRTH U S t\
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0 n
B. HOW DID LAST MARRIAGE END? (3)t'J DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTJ 'I / 6A; / \~J; 1
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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
DEATH
DEATH
1
,
o
o
B. HOW DID LAST MARRIAGE END? (3~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? '" / 17 / '1.9.35
MONTH'i:? DAY VeAn
D. ARE ANY FORMER SPOUSE(S) ALIVE? tI?:I 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
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o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22.SIGNATUREOFBRIDE. l~/ L ~~
;~~ USE CU~~ME
1ST 12!17!1D85 Bronx County, N 'Y
2ND
3RD
4TH
1, being duly SWDm, depDse and say that t
as tD my right tD enter into the m i
21. SIGNATURE OF GROOM.
,.
DATE 1")/1qnnn,?
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
{ } NAME (PRINT) Gloril ~~z..? i
SEAL ~~~~1\'~"" dZ;~/. Zf~m1:;1~~002 1::' AM MaN>""
'-v-l s~QTMidd\@bush Rd,\^':iaPPlb\Q~~f~lls, f'1"(TATPS90 ZIP ..:. PM 12 20
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATlerfocCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0'5l! RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. -,. 9 0 OTHER, SPECIFY
17 2003
YEAR
MONTH
YEAR
2002 02
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT':!<otl.lJ_rtlVl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF r-t. TOWN OF 0 VILLAGE OF
SPECIFY 5To IV Y PD l rJ -r
NAME (PRINT)
SiGNATURE.