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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Q"'owe ~ \l\/t,;)lfe
T..1i[)O~ . tDRRENT SURNAME
COUNTyf'li jtr~hp<;.:c;
CITYITOWN V'll "\ n r'li j"lfJPr
DISTRICT", '-l r, n I ~
NUMBER I .:;ont"".
~5~~J~R 1 77
1 A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)..,
D SOCIAL SECURITY NUMBER u69-66-7116
2 RESIDENCE AN YsTATE) B D\tb~~~SS
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND AI .
SPECIFY \'\ applnger
D STREETADDREss1??4 Rnlltp q, Apt C ZIP 1')t:jqn
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs-.(] NO
3 A. AGE31 38. DATE OF BIRTH M~H / Cb1 / 1~l1
4. EMPLOYMENT
A USUAL OCCUPATION Retail
8. TYPE OF INDUSTRY OR BUSINESS Ste'p Be Shnr'
5. PLACE OF BIRTf-8it~mfEi~ ;y ~~SAI
6. FATHER
A NAME George ~~. \^/olfe
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ruth f\nn BrQlNn
8. COUNTRY OF BIRTH U S P.
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (31'l'J DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 11 / ""nn')
MONTH 01. Y -yElJ(
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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
0:
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1ST 06/11/2002 poughkeep~je, f\lew York
2ND
3RD
4TH
I, being duly sworn. depose and say. th
as to my right to enter into the marria
21. SIGNATURE OF GROOM ~
ot'I 1ST07'05/2002 King~ rmmty, ~]E'\f\1 York ~ 0
o 2ND 0 0
o 3RD 0 0
~ 0 0
f that the information I provided is true ~hat I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~;;(' U;J w ~
" USE CURRENT NAME ~
DATE 11/11/?On')
by New York Domestic
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of e 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
w
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{ SEAL }
'-.y-I
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A'TJ 0.. A to Po.
Y.""'..... ....... ,.",,,.""''-0
(THIS SPACE FOR STATE USE ONL Y)
Q'J.; I ~, ) . C ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A FULL NAME FIRST Dc('~Rr L \!olr1E'CURRENTSURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENTM? r),r'IE''' "leI
c. S~~~~~JN~~~~~t~~e~~~bJ olfe
D SOCIAL SECURITY NUMBER 92 -r,6- 7909
12 RESIDENCE AN Y;STATE\ B. D'llkd~~fc:
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^' .
SPECIFY ;::Jpr1r10l"r
o. STREET ADDREss1 ??4 Rnlltp. f:1 Apt c: zIP1 ?~90
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
13. A. AGER_') 13.B. DATE OF BIRTH nQ 01'l /n f (l
_ !lIONTH / L DAY '1 b~)!;R
14. EMPLOYMENT
A. USUAL OCCUPATIONRetail
B. TYPE OF INDUSTRY OR BUSINESsStop Be <:;hnp
15. PLACE OF BIRTrH12~,9~cg~N~~<ilr~9r~SA)
16. FATHER
A NAMERobert MarkiE'lAIicz
B. COUNTRY OF BIRTH I S A
17. MOTHER
A. MAIDEN NAMENancy Block
B. COUNTRY OF BIRTtlf S A
18. NUMBER OF THIS MARRIAGE ?
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 n n
B HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 OEATH
C. DATE LAST MARRIAGE ENDED? 07 / at:; / ')no""
MONTH DAY YEAR
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
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
2:29
AM
PM 11
14
2002 01
12 2003
1 .r;t. CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTy:LA: IJ/~Hr5~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECiFY)
o CITY OF ))( TOWN OF 0 VILLAGE OF
SPECIFY L. ') Pr ~p, A }G1: f2
31.
NAME (PRINT)
SIGNATURE ~