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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Micha~!oRominick ~JJQ~~~AME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Br::m6!b L yrm Oel~U~~NT SURNAME
.J
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE b.ndriello
(OPTIONAL - SEE REVERS~) .
o SOCIAL SECURITY NUMBER 055-74-7733
12. RESIDENCE A. NYsTATE) B. D(~~~rc;c;
c. CHECK ONE 0 CITY IY' TOWN 0 VILLAGE
AND W '
SPECIFY ~pplngp.r
D. STREET ADDRESS 15 H White Gate Rd ZIP 12590
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1!1 NO
13. A. AGE 28 13B.DATE OF BIRTH ~~TH /11.y ,/-j~,~?
14. EMPLOYMENT
A. USUAL OCCUPATION Gr::!phic nA!::ianAr
B. TYPE OF INDUSTRY OR BUSINESS Advp.rtising
15. PLACE OF BIRTH POlJnhkp.p.osip. Np.w York
(CITY, S~TE / COUtITRY IF NOT USA)
16. FATHER
A. NAME Kim !1el\lid Oelke!::
'B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME R~rh~r~ Ann McDp.rmott
B. COUNTRY OF BIRTH LJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 055-7?-.46R.4
2. RESIDENCE A. NXTATE) B Q~t'f.Ress
c. CHECK ONE 0 CITY iii1I TOWN 0 VILLAGE
AND ,^, .
SPECIFY vvapplnger
o STREET ADDRESS 15 H WhitA r,~tP. Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
MOJ.9 / DtvS / yl~80
3B. DATE OF BIRTH
3. A. AGE 29
4. EMPLOYMENT
A. USUAL OCCUPATION Video Specialist
B. TYPE OF INDUSTRY OR BUSINESS Mlllti MArli::!
5. PLACE OF BIRTH Port Cf1ester N€,'P Ynrk
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Ronald Domonick b.ndreillo
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A. MAIDEN NAME Rit~ Ann Tip::!
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
DEATH
n
(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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
W
en
z
W
(J
:J
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and
as to my right to enter into the marnage state. - - ,.-
21.SIGNATUREOFGROOM~ ~C~,Z ~~ . IGNATUREOFBRIDE~
USE CURRE AM
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the 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 only for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) J
MONTH
DAY
YEAR
DATE 10/19/2010
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-I
YEAR
TIME
MONTH
DATE 10/19/201
ers Falls NY 12590
N STATE ZIP
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
SIGNATURE.~
MAILING ADDRE
20 Mid Ie
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
08:4ey..M
PM
10
20
2010
12
18 2010
in
CITYIT
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
3:00 ~ 10 30 10
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D(~~\'
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF !iJ"'rOWN OF 0 VILLAGE OF
SPECIFY <.'""~~S~~\ \\
10 CIVIL
29. OFFICIANT .,., -:-::> b J-. ALL +' I [
NAME (PRINT) ,.... -e v. 1"-." .L-r, '....::>0.. Ie: 0
SIGNATURE~~'~ ~
MAILING ADDR SS
,\>,(j, ~ ~A l( ~<t..WQ..\\ .) d--.
STREET CITYrro N
30. WITNESS TO C
TITLEe~C~kc.:. \)I'~o"'+
DATE~+.:J-v ~c, ';2(',,\~,
v1 S tI. \ :tS3:S
STATEt
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
SIGNATURE~