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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Stephen Lemert
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
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 onl for the pu ose of a second or subse uent ceremon .
~ 24. TOWN OR CITY CLEiRK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) / ria J. M
TIME
SEAL SIGNATU~ DATE 09/06/2002
'-v-' M~"M~8'aiebUS pinger Falls, NY 12590
I A
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIM M. DAY Y 0 0 RELIGIOUS ~ CIVIL
~ r;;J PM ) .:l 0 1... 9 0 OTHER, SPECIFY
~JJ 1J&rCLY
10 -/"-"'0 Z-..
, ~S"fO
ZIP
31. WITNESS TO ~~ONY
NAME (PRINT) ':>"Te.'\It N
COUNTY Dutchess
CITYfTOWN Wappinoer
~~~~fFi 1368
~5~lgJ~R 143
1. A. FUU NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 171 56 2802
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. CA B. 5an Diego
(STIl.1f) (COUNTY)
C. CHECK ONE !J CITY 0 TOWN 0 VILLAGE
AND 5 D'
SPECIFY an leoo
STREET ADDRESS 381 0 Albatross Street
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE?
3. A. AGE 35 3B. DATE OF BIRTH
ZIP 92103
~YESDNO
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4. EMPLOYMENT
A. USUAL OCCUPATION Physician
B. TYPE OF INDUSTRY OR BUSINESS U C 5 D Med. ctr.
5. PLACE OF BIRTH Rochester, New York
(CITY, STATEICOUNTRY IF NOT USA)
!::
6. FATHER
A. NAME Michael Lemert
B. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Caro//rwin
B. COUNTRY OF BIRTH U 5 A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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
o
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z
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NAME(PR
SIGNATURE ~
DOH-9B (11/98)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I.}tJ
lo'/~-~~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
N8n~1o~dythe N~~~~ SURNAME
11. A. FUU NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Nereo
(OPTIONAL. SEE REVERSE) 156 76 629
D. SOCIAL SECURITY NUMBER - - 1
12. RESIDENCE A. CA B. 5819 niego
(STA:rJ) (1: umv)
C. CHECK ONE I!l CITY 0 TOWN 0 VILlLAGE
~~CIFY 5an Diego
D. STREET ADDRESS 3810 Albatross Street ZIP 92103
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE? ~ YES 0 NO
13. A. AGE 33 13.B. DATE OF BIRTH 10 /04 A 968
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Psych%eist
B. TYPE OF INDUSTRY OR BUSINESS Children's Hosoital
15. PLACE OF BIRTH Rideewood. New Jersev
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Georee Nereo
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mari/ynn Fera
B. COUNTRY OF BIRTH U 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
o
o
by New York Domestic
YEAR
02:52 ~~ 09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~'jo1.1(
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
,R'?ITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY f0tFuJ .y; K.V(
f
SIGNATURE~