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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Ebany MgJ~udius Pi~-i{J,..~WiE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dlltr.hASS
CITYfTOWN WappingAr
~~J:~c: 1 3flA .
~5~1~~~R 1 ??
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
V' t, 0 I' '^' '
n.1rilo'01.P e la ~~~'H SURNAME
-1
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 053-97-4035
2. RESIDENCE A. C;TrATE) B. ~rd
c. CHECK ONE 0 CITY Iil TOWN 0 VilLAGE
AND
SPECIFY West Hartford
D. STREET ADDRESS 711 Farmington AVA: Apt A4 Ofl119
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r!J! NO
3. A. AGE 26 3B. DATE OF BIRTH MON~ / D~1 / YEU~83
4. EMPLOYMENT
A. USUAL OCCUPATION Vet Tech
B. TYPE OF INDUSTRY OR BUSINESS MArliC<:'l1
5. PLACE OF BIRTH Saint l '1cia West Indies
(CITY, STATE / COUNTFlY IF NOT USA)
6. FATHER
A. NAME Michael Unknown
B. COUNTRY OF BIRTH Saint I IIr.ia
7. MOTHER
A. MAIDEN NAME Cyrina Pierre-I n11is
B. COUNTRY OF BIRTH Saint IIIciCl
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~*~M~~~rt~~I~~~sefie rre-Lo u i s
D. SOCIAL SECURITY NUMBER OAfl-flA-54fl 1
12. RESIDENCE A. C'~TATE) B. J:1~~rd
c. CHECK ONE 0 CITY [Y" TOWN 0 VilLAGE
AND
SPECIFY WA~t H::.rtforrl
D. STREET ADDRESS 711 Farmington AVA; Apt A41P 06119
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YES r!t NO
13. A. AGE 28 13B.DATE OF BIRTH M~JrH / q,~ /WA~ 1
14. EMPLOYMENT
A. USUAL OCCUPATION Social ""orker
B. TYPE OF INDUSTRY OR BUSINESS MAntia I HAalth
15. PLACE OF BIRTH RhinAhAr.k NAW York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME Roger Eric Weiss
B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME IngA Rastrllp I arSAn
B. COUNTRY OF BIRTH nAnmark
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
DEATH
o
o
0,
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 ANNULLED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
1ST
2ND
3RD
o
o
o
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE
SIGNATURE OF TOWN OR CITY CLERK ~
DATE 09/03/2010
w
U)
z
w
o
::::l
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 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
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
DATE 09/03/201
NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
SIGNATURE ~
MAILING ADDR
2 M'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
09:391-M
PM
2010
11
02 2010
09
04
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D\J-\-~~.t
c. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1& TOWN OF 0 VilLAGE OF
SPECIFY E~< t r\""\'<'\\
1'~CIVll
29. OFFICIANT
NAME (PRINT)
71ill~ -~,~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
SIGNATURE~