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DISTRIC1'\ ....uu
NUMBER
REGISTER'l6 '1
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason R. Burgoyne
MIDDLE CURRENT SURNAME
I STATE FILE NUMBER --,
I (THIS SPACE FOR STATE USE ONL Y) I
&d. Ii, ';{I(I,R ~J~ ~,o~
13; tflt ~ . tJ 6 31f \0/ \
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Jennifer L. Pellek
1 A. FULL NAME
11 A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
FIRST
8 BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. S6~,~~'~~t~R;~E~U:~~RS~46-80-7026
2. RESIDENCE ANew Jersery B. Middlesex
(STATE) ~ (COUNTY)
C CHECK ONE Q. CITY 0 .TOWN 0 VILLAGE
~~~CIFY North t;runswlck
D STREET ADDRESS!:J13 t:) vmage unve vvest
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Burgoyne
(OPTIONAL - SEE REVERSE)'! "7 " A "061:
D. SDCIAL SECURITY NUMBER I.... - t '1- t ....
12. RESIDENCE ANew Jersey 8 ri.~iddlesex
(STATE)..". (COUNTY)
C. CHECK Q.NF 0 CITY D. TpWN 0 VILLAGE
~~~C'FYNorth t;runsWlcK
~f13 B vIllage Drive West
D. STREET ADDRESS
.,
YES 0 NO
:J879
YEAR
08902
ZIP
13. A. AGE23
01
13.8 DATE OF BIRTH
DAY
MONTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Oracle Consultant
5. :~~:~~:,:~\M~s~~d~SCEOfl~~~~:~ ecntllcai ~efVlces
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Data Management
WebMD
15. :~~:~~:,~N~~i;c~~d~l~~, New L1ersery
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMEPaul Pellek
B: COUNTRY OF BIRT~ S A
17. MOTHER O' 1- Ot
A. MAIDEN NAME lana..rt es
B. COUNTRY OF BIRTJ1 S ~
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
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6. FATHER
A. NAME Donald Burgoyne
B. COUNTRY OF BIRTH U ~ A
7. MOTHER
A. MAIDEN NAME Sara Roe
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL A~ULMENT
Dlo' TH
D1fH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. 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
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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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, th
as to my right tD enter into the marri
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
to the best of my knowledge and belief that the information I provided is tru
ate.
21. SIGNATURE OF GROOM ~ .'
23. SUBSCRIBED AND SWORN -BEFORE ME
SIGNATURE OF TOWN OR TY CLERK ~ DATE
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New ork State. THIS LICENSE VALID IN NE 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 CLl=RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J.
{ 1 0 2/2002 TIME MONTH
SEAL SIGNATURE ~ ATE /0
'-v-' M~trMW'(j~ Y 12590 10:23 AM 10
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED
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YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE A~ SPECIFY)
o CITY OF " TOWN OF 0 VILLAGE OF
NAME (PRINT)
SIGNATURE ~