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COUNrv[l1 Itr.rpc::c::
CITYrTOWN\Af a ppi ngPr
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
lar:~ \M Gog~!
MI . URRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
()J;lt
I~.a~-o ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FULL NAME
Ti1f::1ny I\~::lrjnrip P::rn<;;itn
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTE razee
C. SURNAME AFTER MARRIAGE~~~S~'~ -~~gE'1
(OPTIONAL. SEE REVER r
D. SOCIAL SECURITY NUMBER - - ?Z '
12 RESIDENCE AF-Io~!q~) B.Or~~)
C. CHECK ONE ..c CITY 0 TOWN 0 VILLAGE
~~~clF'rVVintpr p::lrl<
D STREET ADDRES!?R 1 R ROllen Street zII32789
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
;UTH -1J~AY {9k~
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl
D SOCIAL SECURITY NUMBER :j07 94 4646
2. RESIDENCEAFlo~ B. O\~
C. CHECK ONE ...0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Winter Park
D. STREET ADDREss2R 1 R RnllPn ~trppt ZIP 1?7RQ
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEso-tJ NO
mH / QQy /1al5
3. A. AGFQ7
4. EMPLOYMENT
3B. DATE OF BIRTH
13. A. AGE27
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATlo~dmini~rator
B. TYPE OF INDUSTRY OR BUSINEssCross COllri T pnnic:: r:lllh
15. PLACE OF BIRT~{J~~'t'~,em;~1R;;Jm~~~)
16. FATHER
A. NAME()ennis Frazee
B. COUNTRY OF BIRTH I S A
17. MOTHER
A. MAIDEN NAMEHazel Sharp
B. COUNTRY OF BIRTtEngland
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. USUAL OCCUPATION M@chanic611 Designer
B. TYPE OF INDUSTRY OR BUSINEssM & \^! Zander
5. PLACE OF BIRT~M~iBgeMli~ylp~ifMiW
6. FATHER
A. NAME Randelll Gogel
B. COUNTRY OF BIRTH U S L\
7. MOTHER
A. MAIDEN NAME L:l 'Ierne Schaofer
8. 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
DEATH
1 0 n
8. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONT93 / &A~ / ?",QAQO
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
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE 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
~
o
o
1ST 0 0 1ST 03/29/2000 Seminole Co., Florida
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, hat to the bes of my knowledge and belief that the information I provided is true
as to my right to enter into the marri estate.
21.
DATE 12tnRl?nn?
by New York Domestic
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23. SUBSCRIBED AND SWORN T.
SIGNATURE OF TOWN OR
This license authorizes e 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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-'
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
1 :38 AM
PM 12
07
2002 02
04 2003
TAT
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 ~CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AN?,SPECIFY)
o CITY OF ti!'TOWN OF 0 VILLAGE OF
S T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)