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STATE OF NEW YORK
DEPARTMENT OF HEALTH
",.,.~FFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tri Cao Nguyen
FIRST MIDDLE CURRENT SURNAME
COUNT,Outchess
CITY~TOWNWappinQer
~~~~~CR~ 368
~~~I~J~Ff34
A FUll NAME
"
B BIRTH NAME, IF DIFFERENT
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rae Cizynski
MIDDLE CURRENT SURNAME
I
~t1l
11 A, FUll NAME
FIRST
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
--I
/16 ./1
IP - ,J( ". ' {; ,X
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Nguyen
D. S6~1~:I~~;ULR~T~E~U~~~~RSEfi92_58-1391
12 RESIDENCE .Florida BBroward
(STATE) (COUNTY)
C, CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~cIFDeerfield
o STREET ADDRES950 Spring Circle Apt 1 02 zlI~B441
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE' 0 YES"'tJ NO
13 A, AGr27 13,8. DATE OF BIRTH 05 A2 1911:;,
MONTH DAY' Y~AR
10 CIVIL
:cti ~. G M. t'2, 9 0 OTHER, SPECIFY
~~~W~~T I1SG-~, fR/tNqS ? 13EU~HI TITLE /2. C. !Z.IFsr
SIGNATURE ~ '/?tJ7Y" I ~~::L- f? /1elll~ DATE (;/J^;l/u.t.
MAILING ADD;U:SS 1/ P
If LUNTCN ,{r; eJMfN'a1!-S h'fUS: ,.1'V I,;'..S-9()
STREET 'CITY,TOWN STKrE
30. WITNESS TO CEREMONY
14. EMPLOYMENT
A USUAL OCCUPATlotUnemployed
B. TYPE OF INDUSTRY OR BUSINESS
15, PLACE OF BIRTBronxville New York
(CITY, STATE C6UNTRY IF NOT USA)
16, FATHER
A. NAMERaymond F Cizynski
B COUNTRY OF BIRTlJ S A
17. MOTHER
A. MAIDEN NAMFJane E Pribu~
B. COUNTRY OF BIRTW S A
1B NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
DEATH
o
C SURNAME AFTER MARRIAGE
{OPTIONAL. SEE REVERSi;i!80-1 0 3496
o SOCIAL SECURITY NUMBER;J U-
2 RESIDENCE AFlorida B Broward
(STATE) ..1.- (COUNTY)
C CHECK ONE 0 CITY"'lJ TOWN 0 VILLAGE
~~~CIFY Deerfield
o STREET ADDRES~50 SDring Circle Apt. 102 ZIP 33441
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE' 0 YE~O NO
AR A~1~
DAY YEAR
3 A
AGr21
fl4
MONTH
8. HOW 010 lAST MARRIAGE END' (3) D DIVORCE (31 0 ANNULMENT (210 DEATH
C DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
o 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
1ST 0 0 1ST [J
2ND 0 0 2ND C
0 0 3RD 0
0 0 4TH
knowledge and belief that the information I provided is true
~
~I
[=-
21 SIGNATURE OF GR
23
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATIONProduct Designer
B TYPE OF INDUSTRY OR BUSINES~ B C International
5 PLACE OF BIRT~i~,~ns~x~~t~~r,!'tOT USA)
6 FATHER
A NAME Chau NQuven
B COUNTRY OF BIRTHViet Nam
7. MOTHER
A. MAIDEN NAME Mintt T I Rrp
B. COUNTRY OF BIRTH Viet Narn
NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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This license authorizes the marriage in New York authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies wit n 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,
r-"-.. 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINTl~lo .
_ TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'-,-I '&I~iddi~b'ush Rd, 2,"24 AM 6
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DA Y YEAR
DATE AND AT THE TIME AND
PLACE INDICATED
B HOW 010 lAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 [] ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
o 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
w
en
z
w
()
::i
DATE 06/20/2002
YEAR
21
2002
8
19 2002
2B PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B COUNTy~rC4(S:S
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ,
[] CITY OF C TOWN OF ~AGE OF
SPECIFY 11lIlflfJlIl/6C/!s !;j-t.L.,
31.
NAME (PRINT)