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nlST'l101 ".68
NUMBER' ~
~E~I~J~1 02
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Seth D. Jacobowitz
I
(THIS SPACE FOR STATE USE ONL Y)
::; I A I C ~ILC N1umo!;;;.n
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f. '1 '.J "...1
I' P) II . vII
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Shiho Yoshioka
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
(L
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE:
(OPTIONAL' SEE REVERSE)
D SOCIAL SECURITY NUMBER
12 RESIDENCE New York
(ST A TEl
C. CHECK ONE 0 CITY"'O
AND 0 hk .
SPECIF~oug eepsle
D STREET ADDRE~ Sherrywood Road
ZI~ 2590
o YEtO NO
1.913
YEAR
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERlY91 56 9308
D SDCIAL SECURITY NUMBER --
2 RESIDENCE ,New York BDutchess
(STATE) ~ (COUNTY)
C CHECK ONE 0 CIIT 0 TOWN 0 VILLAGE
AND 0 hk .
SPECIFY' _ oug eepsle
D STREET ADDRES~ Sherrywood Road
J)utchess
(COUNTY)
TOWN 0 VILLAGE
ZIP12590
o YEt 0 NO
A973
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AG28 13.6. DATE OF BIRTH 07 23
MONTH DAY
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AG~8 3B. DATE OF BIRTH 12 ~4
MONTH
DAY
14 EMPLOYMENT
A. USUAL OCCUPATIOPharmacisl
B TYPE OF INDUSTRY OR BUSINES!)nemployd
15. PLACE OF BIRT;r~~os~~~g~~y IF NOT USA)
16. FATHER
A NAMMurao Yoshioka
8. COUNTRY OF BIR~pan
17. MOTHER
A. MAIDEN NAMLNOriko Yoshioka
8. COUNTRY OF BIR-Japan
18. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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4. EMPLOYMENT
A. USUAL OCCUPATlotPraduale Student
B TYPE OF INDUSTRY OR BUSINES~ome" UniversitY
5. PLACE OF BIR-rManhattan. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAMJ..awrence Jacobowitz
8. COUNTRY OF BIRTLV S A
7 MOTHER
A MAIDEN NAME Wilma Honig
B COUNTRY OF BIRTJl S A
8 NUMBER OF THIS MARRIAGE1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(31 0 ANNULMENT
/ /
(21 0 DEATH
DEATH
o
B HOW DID LAST MARRIAGE END? (3) [J DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
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
ffi
aJ
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o 0 1ST 0 0
o 0 2ND 0 D
o 0 3RD 0 0
o 0 4TH 0 D
and belief that the information I provided is true and that I declare that no legal i ediment exists
22 SIGNATURE OF BRIDE ~ JJj.1/C- ( / ~ .A J - ~h
, USE CUR~C:"J'I-~n~
DATE07/15/2002
21 SIGNATURE OF GROOM ~
23
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This license authorizes the marri in New York Stat of authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies within w 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 C.LERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Glona J. ~orse
TIME
SEAL SIGNATURE ~_ t) TD7/15/2002
'-y-/ ~I~iw~r~btsh Rd r Falls NY 12590 1 :51
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
STATE
27. TYPE OF CEREMONY
ZIP
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY [)(/I-c.he.s
1~IVIL
C LOCATION OF CEREMONY
\ (CHECK ONE AND SPECIFY)
ce':v
IL\, CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY U3;; kepy'? ~ Ie
p
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~