2009
...
tlEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
Search and 0
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the lime the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certified Copy
r7i" Fee $10.00
I!:Jpercopy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certification may be used as proof that a marriage occurred.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or setllement of an estate.
~t;g;:i4,:,~~'f.t';::,;< ,,','~ ":,:c :":. ,', ",. "':':: '., ", ',"c ,'.' ,', .., '~"",' < ~/"~~<~~'::~;r: '<~,>'.:1,w2:'l_,~
~a ^~ "l AAa:::>c I r::."":' t..A8r~AMfS ~ \j ~.. I ~ _ L.AL..L..A" 1.Lr.......
PLEASE PRINT OR TYPE DtJID 1"1 I'''''~ -"""~"l I..:'lr ~
Name (First) (Middle) (Last) Name (Fnt) (Middle) (Last)
~room ALE)<.. t:-DlJARD CXAl...LAGrI--\~ :ride >>E:A i
Groom~A~ Bride~A~
:~ateof 4. \~ .12- ~Dateof L1. ~o . It:.
Residence (County) (State) Residence (County)
of of
Groom k D1)lESEx.. M A Bride DLJ c.+I E:SS
Date of Marriage If Bride Previously
or Period Covered c5 ('). l'J iO Married, State Name
Search 0 . D . -I Uaed at That Tme
Place Where Place Where
LicenseWas vJAPPfNGERS FALLS/ N'I MarriageWas
Issued Performed
(State)
~
N/A
e-A5-r -Rs-\-\<-tl.J, tJ'f
f"'\,"?:':~~~~:~,:1~:<';::::::';";f:\'~';" '~,< ';/::::..::',.~,,<~' " . ,': ," , '" ' ; , "', ':..: ~"'. :"'::':-,'<:',>L ~~':;: ::}'~,>r,: ~':i\:;~ :::
For~~~~;:~I=RIED)
What 18 your relationship to peI'8OI"I whose record IS requested?
If self. state "self.. ~ sc.L.F
In what capacity are you acting?
REOUE6nt\\Gt- NEv-J ~~\
If attorney: N.-ne and relationship of your client to persons
whose marriage record is required.
N/A
~~:~~,~'k:'?f':lj;~yg;~i~~f::;':::>~:'" /', :,,;,;.:< " ~:' ." " 'r. ,,~'~,':';::;~~~:;~',,', '''::::;,~',,:}::~'"<:,::>,;~_
Signature of A~t
~.
Date
.., \2-:5 \.OJ
Address of Applicant
~(PV'J.c..~ S\.~\
NAT1Q:-,~ o\1~O
J-5/o
Please print name and address where record is to be sent
UN.,-reo SThreS Q::.Pr. OF S11rrt:
NAnONAL. PAsSPOR-r CEN1E:R
~ \ ....0 Gl+i:.~ TeR. A\J e: .
o
(PlEASE SEE REVERSE SlOE) ;;:tel"
Andrey T rofimov
Notary Public
My Commission Expires November 26. 2015
, Commonwealth of Massachusetts
,
~.:d'-r rJS0-L 1?('~~o'\"J) f?PJUJC'~ (Lr)j~
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~or~
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DOH-301 (3/93)
/117 (1,:,1 ~()
,}-<)
\~~\,CYl
1 0 ~~ 'n- t-J\ Ai CC)Nc.e~ J
" \j'JouU) L\~E- TO ~\:Qu€S\ A CER.T\+'lro co~
Olf \Jt'1 MARR\A~ CeRl1l=lcA1E FoR ^ PA'Z>~POi<T',
lltis ~ 5 'T1~ 9>ENSll1 \I~ AS " ~E:ro n:> ~Pt\lEL
TD Mb~L ~ \NO~"'- -Ai n-\E- &:() OP ~ ~J
~ \ AM Re:QtJESl1~ 1l4A. lAE- COP'i E::c:. ~\
1:> IREClL "'i 10 ~ ~fbR-r- GENT-aL iN T1tE
~OSE=D eN'J~\...orE:,
PL~E. CoNT7-\a t.1G. /(SAP iF" \ M\J~ Po~11EN
~Tl11~ cR. Nf.t;b m f1.?<. p~ OF tJtj t\ff1...\CA1l~,
l1tAN~ 'feu J
f\-~ ~ B~tJ
~509 .4/2.~~514
ttEt'rlH6RCFN~@'1^~, cCA-'\
.
,
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.. ..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for COe>' of Marriage Record
Search and 0
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefi1s, court
proceedings, or settlement of an estate.
nECEIV'E:.~
__ljJi;;ili:i~j1~~&II:;J:::::<:r~::~;;:E:~;:~"':~1:~:':",:~IT:, ':' ~,'.:~,:;,:':);:Z:,::~:':;i;,:It::'::;~I':~,:l~:m:lg~i~_1t\i~4'"
Name (First) (Middle)
:ride ~af-lut(
Bride's Age
:~ate of i Ie;
Residence (County)
:ride '1Zh!~:!.>
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was .
Performed Frtr- '5" '(. ,
'''"''NM Cl FP'
(Last)
/1/< / f'- c.-<..-
(Middle)
bt!4~ [
10-; rc '3
(State)
//V7-
Icr~
For what purpose is information required?
r;-1S~~G~ t!o-m i"/a.rh,r
J '
r-c.C(/ u ~ re/t-!A4T=
In what capacity are you acting?
t.,t:Oo~
(State)
/Z/f-
What is your relationship to person whose record is requested?
If self, state -self.- .
If attorney: Name and relationship of your client to persons
whose marriage record is required.
~
Address of A ieant I f / /
.;z /6 K 11 b'"b r'" /
/' I'- . // r/ / /'.L... /V'y
J T U1/--c/r:r { I )--s'b(
DOH-301 (3/93)
Date (' /
/; 3C/IO~
Please print name and address where record is to be sent
(PLEASE SEE REVERSE SIDE)
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. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Co of Marria e Record
Search and
Certification
D Fee $10.00
per copy
A Certification. an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties. their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
D Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring o~enal record of the marriage.
A Certified Transcn~~~eb.ectect where proof of
parentage ~pprtaip RItJpL~1ed information may be
required such iiI~ ~eteran's benefits. court
proceedings..oIi~ttlement of an estate.
,,,, ~, ,
"W'~;:::I"W'W,^_'W'A""""'l""""'"'' ............. ..........~. N.... .'-'n.........",... ,..'<N. .." .......v. ." . .' .,. ... '. .'w...' N.... ,.,.w"..~.'.'N-'. w=I'""<<.w.^........"'.'..V."'N',.'W_v._~i
........~:~ ..:=m===:::::.... ................;.x.:... 0.:-;........ ..........-:-.....::$ ,," ......~ ..J'...............v.................v ...^........,............... .. -'I- '. . ." .... '. . . ......... . ""; .;>-...................."..... . " .J'...._.--"_v>' ......... . .;..::-;;~ ~"-':,~x..N,............':<:.:-:-ili::::...::,:?..".. ~9:-:::"";-: ~
1iM,i',_iW;:d~$)hL:~i:D}::.:;&>.1r;/.~.:;;;'~.;;;.:,.:,..,:<,\.~;;::,... . ....~.> '.:: .:.,'; ;.: '. '..'. '.' :.,~' , ,...;3>~t,.:..v ~,;.}:,::.~.,.::.:~iy{t;;..;d%}U )!;f~t;ii.~;)l;1Ji.ttIi;_\ ?
PLEASE PRINT OR lYPE
Name (First) (Middle)
~room /?u:- S@o"'( t/1t
Groom's Age
or Date of .!) j I
Birth -::J - G -)- > (/v' c.-l_s ,.. A/
Residence (County) (State)
of
Groom I
Date of Marriage
or Period Covered
b Search
Place Where
Ucense Was
Issued
(Last)
6-0- ~ '-I ~
....) '-' >'\ ~
For what purpose is information required?
/~J-
In what capacity are you acting?
//...~ /.
(First)
(Middle)
j/\/f
(Last)
Name
of
Bride
Bride's Age
orOateof
Birth /
Residence (County)
:ride I.... L-
If Bride Previously
Married. State Name
Used at That Time
Place Where
Marriage Was
Performed
t'l ..... c..
/2
~
What is your relationship to person whose record is requested?
If self. state -self.- ~-e ( /
If attorney: Name and relationship of your client to persons
whose marriage record is required.
i!tJ*:;.~):1w.jj.~1i~;:~t:.[J~~:::':::ili:~~'~:.lt:G~~:~;;;~.:.;::~~D.:.r:i:~.:. ::.;: ., 'f'::::":.. '.'::'::.' ,;' . ......:..::::.... .':"', :..f;.".:~:~:~:~;;::~.>.l.::.::,:.::~:l:J:;::I:~~:k~lli~~;2I~~011tl.l**1fjt;,iJ.:~t_
Signature of A~~_
, -...".".............p-
:.:---~
Address of Applicant ------.
(.; )..'-";)- ifuuJ v, I cJ.. 4 J.J~
J. c- J_ I~., I
.-
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DOH-301 (3/93)
Date
..J. - J u_ <:.)
Please print name and address re record is to be sent
(PLEASE SEE REVERSE SIDE)
~
..
Application to Town/City Clerk
for COe)' of Marriage Record
NEW Y<>RK STATE DEPARTMENT OF HEALTH
..Vital Records Section
Search and ~...:lE.
Certification' Fee $10.pq
per copy
A Certification, an abstract from the m 'age record issued \.J
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Certified Copy 0 Fee $10.00
2009 . per copy
1 ~rtified Transcript includes all of the items of information
occu, r.:r.io~1he original record of the marriage.
'M!\. (;L:_
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passpor1s, veteran's benefits, court
proceedings, or settlement of an estate.
_Ylfs;:ru;:f!t;;1I1ii~i1~Z:,j ~::'J;:::';::r"'::)'::~':~.::: ::.,~.-~.~. ,'~~::~,~:.:Z:::'~:::'~::&;::~:.':::..;::~r_::.r::~1;~:~:.:~_rffi!tll1'l.~
PLEASE PRINT OR TYPE
Name (First)
of
Groom
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
Search
Place Where
Ucense Was \D W V\ DF- WII {),fl,
Issued I./'-f/ 1../
(Last)
~
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
MarriageWas sr. ~ (-5 ~c:!J,
Performed
(First) (Middle)
~~D.
Y)do h4
(County)
(State)
N
(State)
\ I 0(;;
For what purpose is information required?
Y\~ (~h~ ~
iDv-' ~y~\
In what capacity are you acting?
What is your relationship to person whose record is requested?
If self, state "seIf.- \.~
If attorney: Name and relationship of your client to persons
whose marriage record is required.
\d- 3)\01
Please print name and address where record is to be sent
~
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
..
,
;-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital RecorcIs Section
Application to Town/City Clerk
for COe)' of Marriage Record
__~lJjliMWJJiiiJrDl:;~l:i:::~~~~;,:"~"',>~::;,^,,,,,,,,,,, \",:,,:; :~~,: <~L~:~:;<~:::;;::'~:Jm~8~._
~:~~~ 0' Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
f\::I Fee $10.00
(!,..6Vper copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
Search and
Certified Copy
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
tkI_f!:t;:~k;fi::'~:t:;:::::::::;j:{;X;8tr::'~:~~:;:~,:: ':~'::S:'{::~:;:::"~':~~~?, '::,;:~' ,~:,:' ,V^ ,', ;.;,.:~'~ :;L7':w:~.'/',:~:;'~,<,;~'::,:..;~: ;i11:_;1.t~(jtBt__
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last)
~room " \ S !~.f -t ~
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
b Search
Place Where
Ucense Was
Issued
qJC)
(State
~ss
For what purpose is information required?
/()Sf ,fY7tlYrltlg-L 1/ 'c '
In what capacity are you acting?
Name
of
Bride
Bride's Age
or Date of
Birth
Residen
:ride fL' ncS S
If Bride reviously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(State)
/l/
\Nhat is your relationship to person whose record is requested?
If self, state "seIf.- .
~/j1
If attorney: Name and relationship of your client to persons
whose marriage record is required.
DOH-301 (3/93)
PIeas8 print name and address where record is to be senl
(PLEASE SEE REVERSE SIDE)
,
;
J
(
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
D Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
_............... ......^..........".:-...................................."'^"-'"..............'-.., .....n...........,.... .,-y~.'...... , . 'I. "\."' ....__....".'-y...........,....v,... '-"-"....""-..1',................. .... .F..~~_=w,........^....."'^-...._'
................ .......: ,', ........-........ ..."'...........~..'^-. .....V'........^. ............. .......:;QO;...... -. ... -""...."> .. ..."< . ......... ..V'^.o:....;....... ....'-.-"-"v-,.-.-. .........?... ^,.,ox'" ........ .,:::>;.~~: ';-;.;..;...........^...::..'8.....~ <;
d...iti~2i:t:;::;urid,~~:: .;L:,;.:.:L.><:;:~~;~::..v .;~:~;... .,.,., :~;. :... ....,.., <.,': .:~:.:::::.;;;::...:'L:;:0:.':';,.C:y..;~~;~re;fkf;),'> ~Mltp. ~
Il1lil;II~I;lttl:~i;t!~1;:t1:t~;~;~:;:~~::tJ;:;~.,J:~~;::::::::;.:?;~, ;~\y~::~'t:~ . ,::."";. .' .>:.:;...:<~...:~::.:.:.;:t:;:::::Y::7~:!):i;:G'<J~:iY::::::~!lt~f.j:~~'it.181!tllili
PLEASE PRINT OR TYPE
Name (First)
:room In
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
b Search
Place Where
Ucense Was
Issued
(Middle)
(Last)
;.(:{ 'n.'
(State)
~
~~
2. )<-\-Os-
W~PI nW(:j~llj
For what purpose IS Information required?
D~~
In what capacity are you acting?
Name (First)
:ride 0J\J Ct\'l n Q.
Bride's Age
:~ateof \ 0.2- . BL\
Residence (County)
:ride ~-\€~~
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was W (b rD f\. ~ rS ~
Performed ~'r ' 0-
(Middle)
(Last} .
sch,D n I
(State)
N
What IS your relationship to person whose record IS requested?
If self, state "seIf.- ~_~ \ P
If attorney: Name and relationship of your client to persons
whose marriage record is required.
DOH-301 (3/93)
Please print name and address where record is to be senl
(PLEASE SeE REVERSE SIDE)
..
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''t-.
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for COe>' of Marriage Record
Search and D
Certification Fee $10.00
per copy
A Certification. an abstract from the marriage record issued
under the seal of the Health Department. includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
D Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
=_.."r....... .w.....,.., '. .'. ..,..... . ...... .............m.." w....v.,.." .,......, W."w. .,. '."'.. ,'..w. ...... ~='.~"'""".."I~
.... ..x-;.;........... .........;........{..../....jo... ..~...... ".... <<... ........... .............-....A..-...~...... ......... ....-;..._0' }\":- . <,".. ............""'.... ..<<...j'......;>..............,'......... .......... ....... ^ :..../. ',' .-;.;. .x:;;;~ ;<;-y,wo..<<...... ^:::w
L .'*'fUL:::L;X;'"tittfi0~L.;;.:,.,;;: .",)V,;;;.:.. ..~ ~~:'^:,: ;, .;\.: < . ....,.:..,::.;;.,.,;~,.,..::;&);,L~. <<..::;,~:>:)::;::..:..: <~~g;;jfNrk MfAtt 1: .
PLEASE PRINT OR TYPE
Name (First) (Middle)
~roorn (J {1 /~ J1~tf j'.
Groom's Age
or Date of / J
Birth /j I:; JI19l-/Y
Residence (County)
~roorn I Vh k
Date of Marriage
~~=hCovered Fe h /0' I f?r:P
Place \Nhere
= Was 70Wf1 II j. j/// a
(Last)
\). I' / ~()h
(State)
For what purpose is information required?
In what capacity are you acting?
Name (First)
:ride !3ti/f"b~ /X
Bride's Age
or Date of
Birth
Residence (County)
:ride PCA/clll/./'
If Bride Previously
Mmried. State Name
Used at That Time
Place Where
Marriage Was
Performed
(Middle)
It
(Last)
SJ11t( ~
(State)
It. I
What is your relationship to person whose record is requested?
If self, stale "self.. .
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of ApplICant
11.I.iliij1:1;~il:)::i\~::;t;:F~~:~r$.ff~G;~;~::;;::r:::,;;'2::.:;::.::::;~. ',:~::'T:';:::.': ':: .:: ::":::::;""" :;:. '..: ~.::. .:;.);::~L;;.::;:::::)~:::::~::;~>:::::~[;:,::ii::)l4~i:lililb'tii1it111R
Date
Address of Applicant
Please print name and address where record is to be sent
Jl/s-- ?tf7-i(7/:;-
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
~eWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
__MtX'~"""""W""""""'~'~^"'<""'~~'V"'N"""" .. 'x' -.,.. .. """~m"V ~ .A"" ,,,w'W'~~""^d^""W_'
.. '":;> ;. ;..J'.... '".................:;~~'~'\?_...>V<..'" ............-............."^ "V ... -.,: /'. "' ... J'. . <. "h'- . .. ", .........,;...-%:;:,...... .......t;.............{'... .~...... .............v '-:-. .......~~ .......
.%,/:::,n~)~F#it?~;:1~:"-;i-:<.:>d:...../.'\.. ,',.,:.. . ,', :J: .,'~ ,;:"'.~;,.< ';~.,:X{:>:..:::;.:';tt;:;HUr&}b%.'*\>>::: i
;xx..........:<<$.;>>--:..~x.t;:..wm~~-:::-......~<<.->>:-:...->>:....~~....... ......~.:;;xx........ .......... <:.. <<..-,... ................-. ...............<:... .....t.".:C:.;.::-.:=::%...x ~x."v~%~~?0'<::% 0'
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their resic:tence at the time the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certified Copy
~ Fee $10.00
~ per copy
A Ce~~rip! !1'!c1..udes all of the items of information
occurring ~ ~1ViU'tIl99rd of the marriage.
A Certification may be used as proof that a marriage. occurred.
A ~ript rnaYJJe needed where proof of
parentage aKHlf!6rd1in oit\il lietailed information may be
required v teran's benefi1s, court
estate.
_t~i~).}~t:~~'~':~,:~&:iL~~n:':?':,~.:':::'~~:~;~,::~:::'i:::"\'~'::=:::.~'~: ;~::~:.:~', .' A~ '...~:~:<.:'" :}l::::~:::~::::::'~f.;:~.'1':I:::~;:L'.~g_lttw)'1__1
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of ~ .tz?/eAJ ~O{(N rn A .:twa1 of OI<AJ H..<....k- (.if ill rn 1-7-t:t:!! ($-1.
Groom Bride
Groom's Age /qSJ Bride's Age Ob ' I (- IC( 6 r
or Date of oJ. J)'- or Date of
Birth Birth
Residence (County) (State) Residence (County) (State)
of u},.~ 1'1::--<<" AJ c-w t.( 0 fUr of U /.,11 e"'&y?'" AJ t:? vJ I( I??K.
Groom Bride
Date of Marriage If Bride Previously
or Period Covered {);(,RO- /OlQ } Married, State Name
by Search Used at That Tnne
Place Where LV A- Pf{.N b1.-~ S Place Where
Ucense Was ~<-j .Vv' Marriage Was vU ft('fl N IYC-'" ~ J F'Mlf V('
Issued / ( Performed ~lt;;;i~rf;_;2z~:::~;~1;r.~itl;;:::::iif:it.:::::~:~rt&;~:~::~liC~~:;::]:::IJi:t:;:;'::;;:;:!:', " :~. ~::. ':. ' :. !:" . .'. .: :; ~ ......,., ~.:,: :.~:~~~ ~:'.::': '::(:;:r;r~::Tr:;::;::~:-::::::i~:::i;:::::::'?~r:i~j,~::m;~~lr:}\;~!t:~:['1 j
For what purpose is information required?
~t"&-(sm,<- l~u~12(2LA-lk- /).J 1tl4
What is your relationship to person whose record is requested?
If self, state "seIf.- ~. €3Lr
In what capacity are you acting?
't~F
If attorney: Name and relationship of your client to persons
whose marriage record is required.
iI~~R_tj:::::j:~if;~~;::::!::~;~~:;,t:}2~:i;~~;:;::::::::;:~~:~~::~:j::~:;2~~. ~;::. ......::. . i : ,:' :::~. ~..,.:::; ~;:::::::.::::(;;:::::1::::)}:(;i~~~:::B~iiifJ101i1}_~r_
Signature of Applicant
Date
/l 2 r - 0 '1
Please print name and address where record is to be sent
O~ AJ G" L.L A Yl1 t4 t:- kJ CA
I 00 I J.bxJC I==~ ~
.AJ 0U PM ~l .Vcr
lY<..
Il~ 0 /
Address of Applicant
A OOT t... i.1) 0 k:... f4R #L fJ/Z
(,1JcJ?1\lJ PM- (t- ~ 111 r (2 S0 I
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
*'
NFWYO~K STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and 0
Certification Fee $10.00
per copy
A Certification. an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
PLEASE PRINT OR TYPE
Name (First)
of ..,.
Groom J)~ I) I ~/
Groom's Age I I
~~ate of 9 .). Is" ~)~-
Residence (County)
~roomO u felV' <;" S
Date of Marriage I I
~ ~~Covered (p &g- D~
Place Where I A , '- I
~c::e Was VVetppi ): /', t; f-.-ez 1- <
(State)
N"
For ~at ~rP05e is i~rma~on r:ui~
k.c$f fT'jl J,,,,J-
In What capacity are you acting?
Application to Town/City Clerk
for Co of Marria e Record
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefi1s. court
proceedings, or settlement of an estate.
I)~t) ."
)!i+Jt ~( /ui
t()~(pl G (p
(County)
Ouf cA.ps~s
~:me . (F7) (Middle)
Bride '- ({",(t2 J\ (Y)
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where .,
Marriage Was tM
Performed
What is your relationship to person whose record is requested?
If self. state -self.- .
sc./f
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature ~
C/ rY) . V.a..;
Address of lieant
if the k-c '3 l-MLP-..
~{)a.fP)">'\5~1'--S ~L I (~l {Y'(
!JJ-fFO
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
..
-t~ (.,.9 j{ :)OO?-
.
..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Recxlrd& SecIion
Application to Town/City Clerk
for CoeY of Marriage Record
Search and
Certification
D Fee $10.00
per~
A Cet1ification. an abstract from the marriage record I88ued
under the 8881 of the HelIIIh DepeI1ment. incIud8a the names of
the conlracting pertie8. their reeidenoe 8tthe time Ihe Iicen8e
was iseued as weII_ dele end pI8ce 01 birth 01 the bride end
$J'oom.
A Cet1ificaIIon may be used as proof that a merri8ge 0CClITed.
'cI Fee$10.oo
~ per~
A c.tified Tnll8CI ipI includes all of the items of information
occ:urring on the origineI record of the mani8ge.
Seerdl8nd
Certified Copy
A Certitied T,.18CI ipI may be needed wh<<e proof 01
..... end certain other deIaiIed ir~RI8Iion may be
required 8UCh as: pII88pOI18,.....,'I benefits, court
proceeding8. or eeIIernent of an 881lIIe.
, ; %:
PLEASE PRINT OR TYPE
Name (Find) (Middle)
of
. Groom PH' L.l P V I tV t E tVI
Groom'. Age
~0I 0' ( /"1- (1'1 1-1-
Rll8idence (County) (SfaII)
.:.x.n P vrN A M WE: w y' 0 (2. K-
oaae of Marriage
or~~ o8(~~lzoo~
PIece YJhere
Licenee Was
I8eu8d
(1..a8t) N8me (Find) (Middle) (l.aat)
)E"ffMBt<-ilVO:" ANP jl.€"A MIC.~ELE KOMAN
Bride'a Age
~0I 09 ( " , 19"1- 8
Rllidlllce (County) (Stale)
:.. 0 v,e HE" S5 f'/E IN '( o(l...(<.
If Bride PnMoueIy
~, Stale N8me
UIed at That Tme
PI8ce wt.-e
MmiBge Was
PertDmI8d
In what capecity we you Idintfl
tf IIIIIDm8y. N8me n fllJllio.l8hip of yaw client to penIOnS
wtae mIrriIIge record is requi8d.
Signeture of Appbn
~~~S~I-'~
Addre88 of AppIicn
~ 08 D 12-€ w LA Ne:-
e A 12- ME l-;- , tv y' 105"12--
[)()H..S01 (8/89)
0.
IV 0 v €" f'1 B e: f<.... 2- S- I :2- 00 '1
prinI....... adche8 wh<<e record is to be eent.
(PLEASE SEE REVERSE SlOE)
l
.
,'.
,.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
__;Jii$'f''"'''''''''"' ,,",x:x,,,"..w~,^);;w/..,,>>=>w*~,. ^.'. .. '< . " N. . 'v.... <. ,. x.v,.'wt".,..'"'x.."...,M.<<.<<...."."%wm;;~1'"_
;&;11.@tt1(<X1A;:i.,;J^i,~:ilt.;~;$~;~~~;:,,:,... ,:c~,,' ,'; :"'"~c:""'" ,:~"~:,:4:.:~~::;,:~<::~:~.;:;:;~dJtj~I&H*r&k~~
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
1\71 Fee $10.00
~ per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
_'*M:r:,Ji.[l;E:;xrJ:~;;x1.z:.::.c~:c~;Q;~t::~<:::~:~~~:,::::"~~?;~.:"';. ~~:~'".):~~~::~~:'~.2~21C:~;t::::;~::ml~fillli!ttl_..
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (Fm) (Middle) (Last)
of 3- - :to -S- t") of !\ \ l'sO VI J 13" C ~1 ll:::v-
Groom I-:.!\),~ It 1"\ i: i)ut.Hf1L...-rE ~ Bride
Groom's Age Bride's Age
or Date of o~/~{J~G~ or Date of :S~
Birth Birth
Residence (County) (State) Residence (County) (State)
of DlJhk:)~ (\JL{ of \) J \- c. h..t..s S ;JI.{
Groom Bride
Date of Marriage If Bride Previously
or Period Covered O\Iz.~/'Looq Married, State Name
by Search Used at That Tame
Place Where Place Where
Ucense Was U ~J?I!\JU\e.IC) 10\1010 C/~()1.. Marriage WE 'Du \-ffi,e ~s IVy
Issued Performed rI1\f.~tlr@1k_1fu1tZW2:~!j1t~;;.~:;!trd}i:::sr~>;i:i::D::~;:;; ,: .E:'~~<'~;:;~ ~: ..:::,";.:. ~..' . .' :.~: .~~::~ ..'i~~~~::i::;;L::t~:?]\::~:;:;n.::~~\}:J;;!~\'!fK~:~&~1;f&rlrJl~I!~1
For what purpose IS Information required?
Prctf~ o~ VV\U'rr{ot~ }u.r v'\G1V1-\.t.
C:. \l\CI\~ Ii V' ~VtSsF'CJr}-
In what capacity are you acting?
S-e I t
What IS your relationship to person whose record IS requested?
If self, stale "seIf.- .
3-e l f-
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Rit'11tll~}in;::~:i:!;!;;;i~it~:z;i~r$~c~;;ffi::jG~;~:;:;'E;:':::.f::~:.;' /:;.t.~...~~: c '~. : c":.'; '.::.;:::..:~:::.:': ~:::;;:E;/:..::;:;/::::::::~;t~;:I;;:IZt!cit;li~ti__.
\... L1 Vl e..
Nils (Vy \2. ~1Q
DOH-301 (3/93)
Date; .
)\ 30/Z0cJ<1
Please print name and address where record is to be sent
<; 4 W\...{...
'.
;<"
.
Application to Town/City Clerk
for CoB\' of Marriage Record
(
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search'and lxxl Fee $10.00 Search and D Fee $1
Certification Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::i:i:::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::i;::::::i::l:::::::::::::::::::::::::::::::::::::::I:::i:::!::l::~:I.:.i:::_II.,,:::glll::::IBli:ii~:III:::III:::::::::::::::::::::::::::::::::::::::::::::::::::::::;:::::::::i:i::::::i::i::::::::::::::::::::::::::i::i::::i::ii;i:i::::::::::ii)::::::i:::
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of G i of
Groom a r y J 01-] n "L a f f n Bride D a wn Ma r i e Wo 1 e s 1 a 9 1 1 e
Groom's Age Bride's Age
or Date of or Date of
Birth 0 1 / ":l 1 / 1 9 6 4 Birth 0 5 / 2 6 / 1 9 6 8
Residence (County) (State) Resigence (County) (State)
of p C t F 1 i d of
Groom a s e 0 0 un y r 0 r a Bride UNKNOWN
Date of Marriage If Bride Previously
or Period Covered F e b 1 5 1 9 9 1 Married, State Name N 0
by Search . , Used at That Time
Place Where Place Where
Ucense Was Wa i Marriage Was
Issued pp n 9 e r s F a 1 1 s , N . y . Performed S t Ma r y I s Chu r eh
.
For what purpose IS information required? What is your relationship to person whose record is requested?
An u 1 1 me n t If self, state "self." S e 1 f
In What capacity are you acting? If attorney: Name and relationship of your client to persons
S 1 f whose marriage record is required.
e
N/A
Signatu~AZ Date
1 1 / 6 / 2 0 0 9
././ '/./
Address of Applicant Please print name and address where record IS to be sent.
1 7 L1 5 2 US Hwy ":l 0 1 G a r y John L a f f i n
.
D a d e C i t Y , F 1 . 3 3 5 2 3 1 7 Ll 5 2 US Hwy 3 0 1
.
Da d e C i t Y , F 1 . 3 3 5 2 3
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
.
Gary John Gaffin
17452 US Hwy. 301
Dade City Fl. 33523
Dear Clerk's Office
I Gary John Laffin am requesting a copy of my Marriage
Certificate between Gary John Laffin & Dawn Marie
Woleslagle on Feb. 15, 19~
'1'
Thank You For Your Help
Y;Op:lfl
"\
~ V(VU~
"-:;'~"~"'" TAMMY L. MINTON
l~''\.''''~<'' MY COMMISSION # DO 597231
H: ~~ EXPIRES: November 11,2010
*"f Bonded Thru Notary Public UndelWrilers
}{}-/&-o9
.
.
I~
\
t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
~>';;D:::;::~R1;~:;.:.Ix;':" ~,....;;;:~.~~~:<. ' : . .. . ;, '. . :.:: ;':..';ji~;,~;,.;,,~::::~j.'<':~J~;8.:;\\~;'
Search and D
Certification Fee $10.00
per copy
A Cerlifica1ion. an abstract from 1he marriage record issued
under the seal of !he HeaI1h Deper1ment, inclucles the ranee of
the contracting pm1ies, their reeidence at the lime 1he license
was issued as well as date and place of birth of the bride and
woorn.
A Certification may be used 88 proof that a marriage occurred.
S8lRh n
Certified Copy
~ Fee $10.00
~ per copy
A Certified Tl'IIn8Cript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
perentBge and cet1Iin other detailed normation may be
required such 88: palI8pOI1s. veteran's benefits, court
proceedings. or selllement of an es1Ide.
:;i.;~;~:'.:F'::.":;:~;." . . '.: " ". ," v ""'.' ../}:';:': ;.::':' ." ://:..::;~~~.~:~It;~
(Last)
>tn j -;-/1
/11{3
(State)
Name (First) (Last)
:. I/, II;~
Bride's Age
::-or ./'he ei1lblJr' 3 / q If 3
Reeidenc:e (County) (State)
:ride u:tc;' q
If Bride PreviouasIy
='=r:"e II, (/; > J. Hfl/g
PI8ce Where
Marriage Was f) /I
Performed rri Vile n ol11e .-
For what plI'pOS8 is information required? What is ycu rel8Jionlhip to person whoea record is requested?
W;fek Sec)ltl ~cu,.., ty Ch'/V1 If............. )( 5i./~
In what capacity are you acting?
If anomey: N8me Md relationship of your client to persons
whole marriage record is required.
,(:<~.;':'::::~".<.~i;J:i'..: : ;. :. ..':" " .: :. .~.;.~. :. . > .' '<.:". .: <J;~
k;V~-J;d4-
Address of Applicant
I{o Lf !< t)~ Sf,1/ d 't f( (;J Q cI
f/~ f<'~tll1r vctf!.L7 I {\If
I), ,t?-751
DOH-301 (3J93)
Dale
1/ /2--100
P'-- print name and address where record is to be sent
~
, C"'
7 ti ''''1 e
(PLEASE SeE REVERSE SIDE)
.
~
;
..
Application to Local Registrar
for COe)' of Death Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
FEE:
Na":l~f Deceased j At.
V-el'lf'll-7 I"IIl-UIL-
First Middle
Nam~1 Fatper ofLDec~~
I \I'p eJI~l r.Jtl~,)
First Middle
Maiden Name of Mother of Deceased
~~~
<l~:
{ :.: ,. .: : :t." : ,~::; :;~ :; :':
Date of ~ath or Period to be Covere y
U~I' L '0) ~ 0' 0
Social Security Number of Deceased
01f- ~O ,. -Z o?~
Dat"f Birth of Deceased.-/
LJ(p~. L " la~
First Middle Last Month Da Year
Place of Death -Ll. -~ / I '", A . . \!J .N II Ii
'O'}'2 S:f)fi2 \IV~ yrl"'~1 vvMrft--Jr;t4? Ill> L;,f'/ '1 )'~5q~
Name of Hos ital or Street Address Villa ,'fown or Ci
Purpose for Which Record is Required
Age at Death
3/~
'Yv~c~t'YS
Coon
What was your relationship to the deceased?
In what capacity are you acting?
If attorney, name and relationship of yo client to deceased
'l!'/L--
// I
~t~ 7"'J
Y I I ')....( ~ 0
Signature of Applicant
Address of Applicant
Number of copies requested with confidential cause of death
_ Number of copies requested without confidential cause of death
Name
Address
City
State
Zip Code
DOH-294A (6/2000)
;a
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for COe.)' of Death Record
,
f
..........................
.........................
...........,.....'....... .
...........................
.............. .......
':~:PtUSE:!Q.., . R...]~ORMIAND!!ENe.L..
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Name of Deceased
Ko6erCT -r
First Middle
Name of Father of Deceased
~CJht'~
/ Last
'::, ,.".'
Date of Death or Period to be Covered by Search
1/-<(;- 0"
Social Security Number of Deceased
First Middle
Maiden Name of Mother of Deceased
Last
Date of Birth of Deceased
Age at Death
First Middle Last
Place of De~ ~ /J '\_
I Lf tf-(dct 5 7l' A..Je 7511c~
Name of Hos ital or Street Address .
Purpose for Which Record is Required
Month
Da
Year
V!JAfP I 'MJ GY"'"
Villa e, Town or C'
\J" tz..t;-cj 6
~oun
-=r:.t\ ~ ~<!.-sL-
U'
Signature of Applicant
Address of Applicant
Number of copies requested with confidential cause of death .
_ Number of copies requested without confidential cause of death
State
Zip Code
DOH-294A (6/2000)
"
VI
\V
~0)
:$ 0
.::2:26
I
00
-1-\
~ :::::::.
~
~
~
'..
....
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Local Registrar
for'Coey,of Death Record
FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.
Name of Deceased
0'AJ-{ e S \S05E f H
First Middle
Name of Father of Deceased
:::rose(Jtf
First Middle
Maiden Name of Mother of Deceased
E" ( zA:-l3e:rr-f
First Middle
Place of Death
I 5 vJ &.;1 M.Jr:f) CM.N <Sf.
Name of Has ital or Street Address
Purpose for Which Record is Required
J-voAJ~
Last
6/~/ oif
Social Security Number of Deceased
~~
LyolJ5;
Last
2A-tiN
Last
Date of Birth of Deceased
7!::l.I!;Q/Q
Momh Da Yem
Age at Death
Zg
wAfP I Ai G-t3rt.5 FIfU5 ;J1
r
Villa e. Town or Ci
PU.TctfG-.S :5
Coun
f5) E' (r') re. · . ! i\ ;/ j c-" :-\j
lru ~ '(':J If;., U Vi t;, t.0
What was your relationship to the deceased? .$()N
{< c-t.AT1 J t:
!A
Date
In what capacity are you acting?
If attorney, name and relationshiP"ofY'jClient,to ,dec" eased
, c, "J
,.,- .' -, .,c~'
. '" ,. '"
/ . / / 'i
. . ( , :5 ( ,
Signature of Applicant (_. '7 <3;,'/", / ( - '--- i-:5;~'/
Address of Applicant g O:tfe-.O.AI I 6. /hi EllfUb L17lIt1M.AJ Y I iJlf 0
,
~ Number of copies requested with confidential cause of death
_ Number of copies requested without confidential cause of death
Name
Address
City
'"[),4N/Gt- B. t.-l(a-JJ5
8 CO!AJNI E: ki!EIVUt;;
LftIH A /v't
State N )'f.
Zip Code I ''J If ()
DOH-294A (6/2000)
\..
'"
DANIEL B. LYONS
8 COLONIE AVENUE
LATHAM, NEW YORK 12110
(518) 785-4640 - Phone
Email: danlyons@earthlink.net
April 29, 2010
Mr. Chris Masterson
Town Clerk
Town of Wappinger
20 Middlebush Road
Wappingers Falls, NY 12590
Dear Mr. Masterson:
I'm writing to request two Certified Copies of the death certificate for my father, James
J. Lyons. I have enclosed a completed, Application to Local Registrar for Copy of
Death Record form, and the fee of $20 ($10 for each certificate).
Thank you for your cooperation in this matter.
Sincerely,
::.,r"~--""" //
........-.............-j ..,,;,.,/ ../,
/' / :/ -<,.: -
c-;Ai/a(~ ;) / ~;~
Daniel B. Lyons /. .'
(~1-
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1 Ii ~
,~ I
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'r L~, -ill) r""- ? tJ I (), kO{c/r~"
.'t,
(,i'Ll_A. '
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PEARL ELLEN RO&<
Notary Public, State of New York
No. 01 R0502?790
Qualified il't Albany County
Commission Expires Jan 18, 20.1.:1.
Road Test Columnist - Times Union's Automotive Weekly
Syndicated Columnist CSUV's) - Motor Matters
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Calendar Photographer - Avalanche Publishers, Brown Trout Publishers, Barnes & Noble Publishers
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