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2007 6. Application to Town/City Clerk for COE!}' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and n ~ee$10.00 Search and D Fee $1 0.00 Certification d- Certified Copy 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. ~:~:::::~:::::::::::~:~::::::::::::::~~~::~::~~::::::::::::::::::::::~:::::::::::~:::::::~:~~:~:~::~:~:~~:::~:::::~~~:~:1::::::::::::::::::::~::::1.:..:::_11.1~::I.I:~::.I::::I..II::~leg:::~:::::::::::~!:::::::::::::::::::::::::::::::::~::~:~::~:::::~:::~~::::::::::::~::~:~::::::::l:::::::::::::::::~:~:~::~:::::::::::::::~:::~::~:: PLEASE PRINT OR TYPE Name (First) of G Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where Ucense Was "'" 111--. I ') Issued . ,~ () (A./ f\., For what purpose is information required? ~ Name (First) (Last) of -<: Bride ~j Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where I --e 3 76 ~:~~~~was LJ hMe ~ f~~tu F (Middle) f? zo/~3 of W (State) ~. What is your relationship to person whose record is requested? If self, state "self." /{) tp In what capacity are you acting? XJ-2-fJ If attorney: Name and relationship of your client to persons whose marriage record is required. Sign)J~ f2 I ~ih Address of ^-.PPli;"t /'" ./0 _ d. ~~ 10 (2 :3 ~ f'I {i{l rc:e,,-/(.4 &-~ ~ Cj W/~{/Jt~ I 2-$9 () Date Please print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) . t RECE\\lEO j)tt, _ l" 2007 ,OWN CLERK Mo l?Jl!1 j(p S f,'j..PJ) ,. N rJ{ (; j;/I ci1 I, ~ e. (l e r.- c;o G~u0-3hty 7 6 2'f () (..l(\b 0..., ~ P- S' yv Su (\5 E..+ (3 Ea.-chI N C :J..?Lf 6f? T~~ ~;~ 1) lJc~~ ~ ~ (L .~ <f: ~ -ftL<'~~~ H l' 5 ~"d - \-J G..- tt€- \<..- \= U ('-. ~-( 1\0 \1 g - f? - 'I? Se\~ - -S0-/1n(\ /-Ioy \>0 ~ 5" -/8' - L/ 7 - /)~~ J'~ 4J ~-L~ J o-A {\(\ L, \J\t_~h-+- 0'\ a.. L J el' (\O-Me CTo~Ilf\{\' ~"'l~jo.- Wr,.~h1) ~ G ~ ~ ~ IQ10 -197'1 ,'):m ~ ~ ~--L~'-- ~ L)~ t:~<< fl4~ lj). ~t~~k'~ I? . p.J -\N~W ~ ~~.~~ ~l=:Ji\~Ld;;eke~'L V~~~A-JJv~~~,~+~ /vlJ~ p~~ ~. TL ~ ~ Q.ft-m- ~ k~ /t~, r}~ 4..u.IlJl- ~ ~ ~ ~ ~ ~.-uA~ T~ r/ ~~kdL- '".. .' , . '''''' .-,-' --'---..-i..;.:~'T-;-'------~ --- -..---- l\.T.P. 'AT YORK ST;:\'TE'-'~' ~ ~..L... . ~'-" ID729ones6()"'962' DRlVER..'L.ICENSE DOB:05-18-47'C.'.t~.\.: KELLER,J~ANN L"'> ~1_ TOPLANC RD'~:":' =PAC, , >;tr.' . . .-. SEX:-F EYE~:ttAlki:~i-OO. - -CLASS. .: 0 END' REST E"-':'::- .: ~t :f~~~'.;O , ,-.: .: 47940270 .: ~ I{~ ~ ~~ {;YV'- IJ~, 2~ ;J.oo1 ~~L_-~ :~A!.;l'':< ( .(o-'{ ~=t~~~ '()~!.~-- C')L)(jY V'L~' ._l~/_lii~___-{~~iJ!-'-~ S+a~ oj CA:i~ _Su--?-~.J JS~.f/L Application to Town Clerk for Coer of Marriage Record .ill;ll:jglll~IBgQgl!III.<i~:~p~.I~:r}U: NEW YORK 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. . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . - . . ................... ................... ................... ................... .. ................... . . . . . . . . . . . . . . . . . . . :1!;~~e!:!!aQMee.EI~.!i~l'-rt,M::~~@!fI:~MI.m.p:i!..!.:.:..!:..::.H FEES: Make money order or check payable to New York State Department of Health. Please do not send cash or stamps. There is no fee for a record to be used for eligibility determination for social welfare or veteran's benefits. PLEASE PRINT OR TYPE Name (First) (Middle) of Groom Groom's Age or Date of Birth Q Residence of :JG Groom I Date of Marriage or Period Covered by Search I ) Place Where License Was Issued ....................... ....................... ....................... ....................... . . . .. ................, ..... ....... ....... ....... ...... ..... ........................................... ......................................... ...... ...... ....... ....... ....-.. ....... ........ . .......................................................... . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Last) (State) For what purpose is information required? L&P .:J In what capacity are you acting? SzIF Search and Certified Copy 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. Name of Bride t, Bride's Age or Date of Fl Birth IV Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed ( First) (Middle) (Last) c / 1Z /17..- (County) (State) What is your relationship to person whose record is requested? If self, state "self."_ ,':::(sJ \ P If attorney: Name and relationship of you whose marriage record is required. Address of Applicant DOH-301 (3/93) /2 / 0 Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) VS-34M ( .. .... ....... ":._ ...... ,~ ... .... . .".''- ~^A"'A^A~A~U^!.^\!_I~} II I;~~ . .. .. - . , ...,""/"'...., ~ I ......~....1'l..9 ,. . '!l'l"~'''1'!''! .. ~ StiNOIOVDldl(JOW .. ... . .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record Search and ~ Fee $1 Search and D Certification 0.00 Certified Copy Fee $1 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. :::!:::::!::::::::jjjj:jj:::::::::::::::jj:jjj::j:::::::::j:::!::::::::::j:::j::::::::::~:::::::!::::::::::::!::::::j:j:::j:j::jjj:::jj:j:::;:j:::;j_I:::_1111.j:::IIBI::::."'::::I:IIII;:!:I.ljjjj:::j:j:::;:::::i:::iii::!:::::!:!::!::::::::::::!:!:::!:.:::::::::::::!:::::::::::::!:::::::::::::!::::,::::!:::::::::::::::::::::::::::::!:i:i:1 PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) of Fvi" of L Groom Bride J Groom's Age Bride's Age or Date of 9 - 8 - 41 or Date of 5'- I g-- '1 Birth Birth Residence (County) (State) Residence (County) of NY of Groom Bride Date of Marriage If Bride Previously or Period Covered Married. State Name by Search 3 Used at That Time Place Where Place Where Ucense Was Marriage Was Issued Performed (Last) (State) '( For what purpose is information required? M~ 1~~o.~ What is your relationship to person whose record is requested? If self, state "self." _,g 0. ~ :J . It attorney: Name and relationship of your Client to persons whose marriage record is required. Signature of Applicant Date Address of Applican C/o <;€.\O.-S"\Y '7b~~ SU(\ S\J l)~. C 2%,/ &f' 11-:1..5"-07 Please print name and address where record is to be sent. j Ke...lle\ C{ 0 G ~ \'0..-9 \-..-t"y .s hi 7b:l1./ ~v~"hQ\ 0, liP v 'r) oS e. e.c...(..:n f0C J.. g 't to DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) STATE OF NEW YORK Department of Health No Record Certification - Marria~e District No. 1368 THIS IS TO CERTIFY that a search has been made in this office for the marriage record of Walter W. Funk and Jo-Ann L. Keller which marriage is said to have been solemnized on 1970 - 1973 (Date Marriage Solemnized) , State of N ew York and that such record is not at (Place Marriage Solemnized) on file in this office. Search has been made for the period from / Month / 1970 Day Year to / Month / 1980. Day Year Witness my signature this 3rd day of December 'fC1q~~ ~ 2007 City } Town Village of DOH-3654 (4/93) Town of Wappinger , New York VS-13 ...-...... ............ ..... .............-.. ......."..... ... ...... ......_...-....-...._.........---~. ...._...........:L:...-J(~JJ f.,.~.. . .......... .......... ....-....-...-.... ............---......... ~""'''-'''..- .... -..... ................ .... ...".... ....... _..-_._.....__..._..~l.9_.jQ.e.rQ,."g.bt.y.._......._........_........ .-......... ....'.--". ...--..-.......-...-................-........- ...... .._... .-...--.........-......... .--.-..... 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I i I " ", .':--_._._.-"-._~~~.-{.,: . ~"tt ~--;---~~--:-r-~-.-_____.._. ~W_~YORK STATE' . ,ID~29one86ct962sDRf\7ER,LICENSE . .008:05-18-47 '\"~~'''i": . -" " ((.r- ~~ . KELLER,J~ANN L';:'i ~lTOPLANDRD~,~5'; " MAHO..PAC(, "~~"'Y"'" . / .' ' ,J~~1 1\ '~~~c__' '::/ ,:. 'ESEX: F., EYESI.HA,.iHif:6-00 -CLAS'S~.' , D.' '. ' .' NO: R.EST,a~ - ." " ' , 'ISSUED' 05-14-02!}"'-- ~;,,~"" .\ :CL{L' 'X~K~~lB:~:05-18-10 ,,: ~,. .'. ";, . -. ,'egO' \,):, 47940270' , Co ",,1 ~-iL I{~ ~ ~~ tSYV'- I)~. 2Jl1 ;l.oo1 ~. -,:'~"', 9 ~ ......' :~.: " ~~_.;..:'.,~.:,_..~_....__~-" r{\ .J,,- ,.' .,. J '. ":': .-, {vrrlAV-J(;~ /(~,,-,f ~ \,..~,....., . ..., "t ~ .....>~ 1)- /, . - ~.' "'., . ._.::-~::L ~'-~~"'~~'-']-~- "" ,8>L)?'v'vG 'D 3 ')..,}1l rt J~- .il~_~JuoJ-'/rj - '5u/F.4 6p-f/0 S+aL .. Gc:!~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe}' of Marriage Record 1:::: .. ....... -............,............. . ................................ ..:,::::::::::::::::::::::'::;:;:::;:;:;:;:::::::;:;:;:;:::::;:;.:::.;.;:::.... .::::i:~:::::::::::::~::~\::~:~:~:;~~~~;:~~::;~::~;;:~;;:;'::;;'::;:;.;.;y.. ............., ..-.....-...q. .". 'H' ..y........'..............-.-.. .............----...........,... ........,... .........",...,.. .....................,.......-.-..........,.,...,..','...'.-....... ........ ...........-............... ........... d.."..... .__,_. ..... .............................-,....'...........',..."......,',...... . . . . . . . . . . . . . . . . . , . . . . . . . . , . . . . . ............,................. .............. ................ ::.f:.JI:.II:::IIII.fl:f:II~'I..;:rlf:lsl::~gll:;f:;.:.:. 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 ~ Fee $10.00 per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed information may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. ......:;::::::::I:I.II.::~_lg.I:.IIIM..I.lf:I.IM~fI":r~ll. .:'. ...........--.....'.... ..................... PLEASE PRINT OR TYPE Name (First) of '"l'\n. "- . Groom ..!~.n& Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered "'" by Search I Place Where License Issued (Middle) (Last) ::s: ~MG (State) ~ q4 In tYl~ ~e03A$~'4~ ~ L0~L' ~ ~I iAJ...t (d.~O DOH-301 (3/93) ;.:.;.:.;-:-:.;.;.:.:.:.:.: ... . ................. ........:-.........-.-.-.-..'...-.......'..... .... ................ ............-..... 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 Marriage Was Performed (Middle) (L.ast) MOi'c..k (County) (State) What IS your relationship to person whose record is requested? If -. stale -.e"/) R.~ If attorney: Name and relationship of your client to persons whose marnage record is required. Please print name and address where record is to be sent. 3q O~ S~ li>Otd Dv- ~ l~O (PLEASE SEE REVERSE SIDE) f r~",':,.,W"'_,"--'~~-"'''''~~'-''' -"..-.,-- --...", "<" ~,,~ ' c' "...... _, ,'" .. __.. " ',' ""-'0'-' ..-c.,.-....,.....,. _'" ,. ......' c- .. '..f.. ," ','" -,,_, I '" llf......~ t :0211,"'281 ' " ' , " , ~ Application to Town Clerk for COe}' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ....................... '.'!rnleiIE:!g:I@II!llil~llg.tll~91:ln:il.:::::> ........ .............. ....................... ............ ......... ....................... ...................,... ....................... ...................... ....................... . .......... . Search and D Fee $1 0.00 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. .......... ........ ...................... .............. .... ..................... . . . . . . . . . . . . . . . . . . . . ..................... ....................... ........................ ....................... ........................ ....................... ........................ .................... ................................................................................................................................................................. ...................................................................................... !:!!!!:::::!!!:!!:!U!:p:a.s.:....:.E.:....::.:.!.Q................:....:......................:.:....1....::..:..S.....:...:T......::.:S..:..:....::.::.:p. ::lllflld:R:EMm::EEE::!:! ......... . .)))<..... ..................................................:.:-:.:-:.:.:.:.:-:-:.:.:-:.:.:.;.:.:.:-:.:.:.:.:.:.:.:.:.:.:-:.:.:.:.:.:.:.;.:.:.:-:.:.:.:.:.:.:-:-;.;.......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... . . . . . . . . . . . . . . . . . . . . . . . . . . ....................... FEES: Make money order or check payable to New York State Department of Health. Please do not send cash or stamps. There is no fee for a record to be used for eligibility determination for social welfare or veteran's benefits. PLEASE PRINT OR TYPE Name (First) ~room r~~ N'Q.c; Groom's Age or Date of ~ ~~ Birth Residence (County) ~room $r,C\ ~~ Date of Marriage or Period Covered C by Search .....J Place Where Ucense Was Issued (Middle) \0 \q11 (Last) \(Q\ Name of Bride Bride's Age or Date of D) Birth Residence of ~ Bride n \ C\ If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed ( First) fS ~iddle) (Last) $\Clv\M- &. (State) (q GO (County) (State) V\) \q<i~ For what purpose is infol1lTlation required? ~QO.\_ \-\A- \ -rSU~ LQ~ What is your relationship to person whose record is requested? If self, state "self." ~ \ ~ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. \\. ~1 e and address where record is to be sent. DOH-301 (3/93) VS-34M (PLEASE SEE REVERSE SIDE) .. -~~.~" ~ Application to Town/City Clerk fot Coer of Marriage Record NEW YORK 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. Search and Certified Copy r-Y Fee $10.00 W per copy 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 settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of m I') Groom Bride lA../ [: JlJ Groom's Age 9 Bride's Age or Date of or Date of ~1 -\ I{ _ )_ ~ ~ 8~~f~ Residence (County) (State) Residence (County) (State) ~room LJ n-\ C ~ E s 5 ;...J U ~fride bUT Q H E S ~ III 7' Date of Marriage If Bride Previously or Period Covered Married, State Name by Search / Used at That Time <::: 7J ~ L( (A tU 212 Place Where Place Where License Was Marriage Was 10 6 'F~'~'~~t'p~~p~~~""i~"j"nf~~~~ti~n"~~q~ired? What is your relationship to person whose recorctis requested? f) - . L /7 If self, state "self." y ~ f},;.tIJ,D1'"1}Y "0 FL F In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date , t. /:z~ A ress' of Applicant ~ 3t/ II {, fiNO/( E j3L.V! tJlJep, F'LS./ AJy /;;; j9D / Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) ~~C~/v. ; rO~ 0 ;*, 'tv 01 ,... 'I:::/Y1r DOH-301 (3/93) -----. . "......~ ... : ,~; llS-1408ll ElCPtREs; ....11 i.1..-"l_-...."'-;.,~___~,~..,<.:-"'-";);~L'_J:,,~...,_ '-..0 \ NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk Vital Records Section . 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. Search and Certified Copy rv(. Fee $10.00 BJ per copy 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 settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name of r., J_ of Groom '. Lawrte.n Bride Groom's Age Bride's Age or Date of J 2/2-0 I ~ \ ('J -"7 '\)' or Date of Birth -I 0 Birth Residence (County) (State) Residence of \.{\ I of Groom NA.V_ e. \...01..11'''\ \L --:.. L- Bride Date of Marriage If Bride Previously or Period Covered I A 1')00 () Married, State Name by Search \.JL j......; A.- Used at That Time -- -- ~ 'F~;'~~t'p~~p~~~"i~ 'i~f~~~aiio~ required? What is your relationship to person whose record is requested? ~-\- e-R fiCA.. -\- j Ono.. l OdDQh 0 n If self, state "self." II~e.I.~ . (First) (Middle) Toni (Last) 01 (State) Lc.. '( <. lL- '- In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date (PLEASE SEE REVERSE SIDE) Please print name and address where record is to be sent. <2>u.1.€.. \-\e.- 3e~~e_ \ l\ 2. \--\o..~\ W 0 cd \)Q. \ \J e... \ ovlld ~ 01 RECEIVED NOV 0 8 2007 TOWN CLERK 470 V(Al)lDodlD~i" ~ f~DIj nc:ll_CL 'Le.. I TL \.Q 0 0 1 ~ DOH-301 (3/93) November 2, 2007 Wappingers Falls Town Clerk 20 Middlebush Rd Wappingers Falls, NY 12590 To Whom It May Concern: I am writing to requests 5 certified copies of our marriage License. My husband and I were married in Wappingers Falls, New York on June 19th, 2002. My husband's name is Benjamin L. Jeckel and my maiden name was Suzette T. Vetter. Please send the 5 certifified copies to: Suzette Jeckel 427 Haywood Drive Round Lake, Illinois 60073 If you have any questions or concerns, please contact me at 847- 304-2025 Thank you! S4 Suzette T. Jeckel 'j .r ^-, I OFFICIAL SEAL 0{tU VGI .. GLORIA A. SARSAM - t-- NOTARY PUBLIC. STATe OF IllINO&S ~-- I U. {)~~w. '1IY~_1_1 " 10- 'J5-d.-Q/! ~ if /llinu1Jr NUMBER ISSUED EXPIRES J240-0727-8361 09-12-03 1.....&1.!.r4 BENJAMIN L JECKEL 320 STRATFO~D PL 21 BLOOMINGDALE IL 60108 Birthdate 12-20-78 Male 6'03" 200lbs HZL Eyes Restrictions. Type Class F ORG D 3." ~ -r=-- ..., NUMBER ISSUED J240-7987-86 .o5 S U2ETTE 427 HA ROUND Jesse White - Secretary of State EXPIRES - NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe}' of Marriage Record Search and c2 g Fee $1 0.00 Search and 0 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. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of 11 , ~( It 7'Ja.Y'1~r of S Y/V;O-. B )q IT-?;p r Groom lC . Bride Groom's Age Bride's Age or Date of I,) - /0- S~ or Date of 9 - 9 -jJ Birth Birth Residence (County) (State) Residence (County) (State) of P utcJ1e IJ'( of /) Jtch e.5J ;1J y Groom 55 Bride Date of Marriage II). /0 If Bride Previously ora or Period Covered 7 I Married, State Name Vi Y7. 'D by Search Used at That Time Place Where , Place Where Ucense Was uJ ({fft "We' r Marriage Was B e q Co J1 Issued Performed For what purpose is information required? What is your relationship to person whose record is requested? ~ S'U ra. v1 If self, state "self." 5 e f F c e In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record ;s required. Signat;J;Z'i~.ang Srat~1i Date /t /0 I II '/luLl. . Address oMpplicant , V Please print na":le and mress where record is to be sent. / to sA 'eafe ~ d 7[ Iv la,- zre Slz -et{~ c:i - /Va f f I h) ~() ~l {s j1J Y /..)J7o 0 f;;1{sr tJ Y /;;l 5"'1 0 I tt~f? { V\JerS DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record .................... .................... ......-,......,...................... I:::';:,:::::'::)l:i::'ll;)::::::I::::::':i":":Im;:,:II::.III_I,:I..II:;(@.I::.I:'::::::':'::',,:,:,:::,,:::'::.':"::"::.;..:.;.:,.:......:...... ... ... ~ \u)'P\~~ d Fee$10.00 ~ per copy A Certified Transcript includes all of the items of information occurnng on the original record of the marriage. .....,........... .... ..,......................-. .................. 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 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. '.:';:':;:;:::::;:::':':;:';:::::;::::;;;::111I111\_1111.":811::_::111I..:&1::::::;;:::':';):':::::::::;::::::::':::::.:,:,:.:,:.::,t,I:lli::::::)l::::'::':,:,:j::':::::: PLEASE PRINT OR TYPE Name (First) (Middle) ~room \V\~YV\~~ Vt ~ V\ Groom's Age \ or Date of ~ \...\ ---, ~ Birth \ ~ Residence (County) ~room \:J ~ '^ \J t '( Date of Marriage or Period Covered C\ 1 \ l a \ by Search Place Where , ~~:ewas 'N ~'{)\V\ eN~ r(\ \\~J"L~ (Last) $ ,'V\ w (State) ~(j Name of . Bride ~~W\~V\J (First) (Middle) ~ l~l~ ~ Bride's Age \p \ ~I\~ (County) $~ '^ \it V or Dale of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was "6 ( ~ ~ ~ V\ ~ \./ Performed ) 7 (State) ~O For what purpose is information required? _nL'NLl-1\A-U ~ L In what capacity are you acting? ureo~J' Address of Applicant 55~ Loq ~V\ ~T \:)t V\ Y ,L~) ~ 0 ~ 01- OS DOH-301 {3/93} What IS your relationship to person whose record is requested? If self, state .self.. ~Q \~ If attorney: Name and relationship of your client to persons whose marriage record is required. (PLEASE SEE REVERSE SIDE) .:s-~!> \.~"L.' 0 ..CllaElpllll.... >f"I{) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record ........................... .......................... . ........................... ........................... ..Jl:.,::.:::::'::.::::"::::.:.::...I..:":::::::.:.:.:::.::IIBI:::B::::I:IIII:li::III"III:jijllllll:j:lllli::::::::::::::::j::::i:i::::j:::::::::::::::::::::::::::::.:j:.:l,::::::::::::::':::I:I:::.:.::::::::::::::::::::::;.:::.:::::::::.:.:.:::::.;,:;::;::::::: ................. ................. ................ . . . . . . . . . . . . . . . ............................ .. ............................ ........................ . ....................... ................. .... ................... ....................... ................. ..................... .................... 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. ~ Fee $10.00 ~ per copy A Certified Transcript includes all of the items of information occumng on the original record of the mamage. 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. I::::i::::;:::::::::::;:::::::::::::::i::i;::::::::::::::'::::::::::i:::i::::::::':::::~:::::::::::::::::::::;:::::::::i:;:::::::::::::;:::::::::::I:IB.:.I:::11I11.g:::IIII::::III::::I:III:::III;:;:::::i:::::::::::::::::::::i:::::::::;:::i:i::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::,::,::::::::::,:::::::::1 PLEASE PRINT OR TYPE Name (First) (Middle) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Last) (First) (Middle) 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 Marriage Was Performed (Last) 52- (State) 7 7 (g~,5" (State) o c.rDBl:::.P- (County) .0. CQf For what purpose is information required? R t=='-ri ~i?M12NI Docuf'--\E:r--J TAll 0 r-J In what capacity are you acting? IZf:.l"JUFbllI\.lQ I, f3r:( 4l ..KF S POUS;c ~E8?s E What is your relationship to person whose record is requested? If self, state "self." l 5 E L-r- t if attol'i'"ley: ~Jai' is and ialationsh:p of your c!ie~t t~ pe!"so~.s whose marriage record is required. Signature of Applicant Date ~ L_ a...e-n Address of Applicant tt-'a4-S ~ - \-'\'\ '<V\.JI..PcL. R..d.... \J\..Y~ NY \4-l?3t / Ou-o~ \.7 2cx:Sl Please print name and address where record is to be sent. {Z.o 1'J f\ L 0 --J A c..l,.L.~ 0 N \ \ 0 Sl m p Son <;' teL n OV' Dr. S, YV\p'Son vi Ile/ k. Y 4-00\.01 DOH-301 (3/93) f ~ E \... f i 'I t-I (PLEASE SEE REV~RSE SIDE) OCT 2 7 2007 TOWN CLERK Tl~ t 7 ;;{u07 I . i'Hr"'~"':'-.. l{et!fu.f;!j!J~ ' ..... -;i _lBTClraoitcrortl F lMl1 .. 0 10-31-" -4IleI _ .~_.'!' _ .Evn_ .~~_ .~ ._. -..t- ........-......, .....- .t. .'&,...... ~L. . \~ \._.uCi...= ~ \....d- -~ ~ -l v~ +0 f^-O"; l ~ 0- Co 'F-'-1 0+ ~V\_J} ~~ ~~. V~ ~ a.--I.....d.- Lu~ l>L ~ o-::t- ~ Q...V'\c1 0+ NOV €.......... ~ ~ h....L...L.c.LS 0..... C-c,p---<-j oF- 0 t....L-A- Lj...,~. r, . "\A~-'--~ ~:"'-..-..::t:...- -~ ~II'-L-"CJ--~ ~~ ~F' I "'~ ~ /\..L.Lo~ +0 N'1. W-L ~ h-L. v~ov~J ~ \ $, of ~~ D-v1 c:...JL h...o.- ~ ~. p ~~ I ~ ;J...~ 0.- C-o~ of- ~ Vy)~ c.. ~~ -I-a ~~ ~'--' K I. e O-S no+e..cL en^- ~ O-(~) n ~ Yo-t...{. I '~~YJ /oJg/o-r ~J?t g~ LINDA M 8 NOTARY . AILEY STATE OF N PUBLIC #4904601 COMMISSION b.~~E~F SCHUYLER SEPT. 8. 20.QJ Application to Town/City Clerk for COe)' of Marriage Record NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section 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 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. '::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::1_1:::11111..:::IIII::::lla::::I:III:::III:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) ofe '\ Groom -,......dlvl+RcJ Groom's Age or Date of '7 12 'r '1 Birth c7"- J ~ Residence of Groom D t/' Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) (Last) (Sa 0 \..vi)-- RltfVCI S; (County) (State) IU -:Jt9 011 'fJ~ u::; f'f""'S ;;200 '2( Name (First) ~fride Ch~(sff/...,e Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (Middle) (Last) W \ f-h~f2-s ~ J.-)..> (State) AI <--( u. w(~ A~R.S f.vIlIPlJJ ~ hz liS' For what purpose is information required? (?- Ifl ,~ In what capacity are you acting? S~ \r What is your relationship to person whose record is requested? If self, state "self." S' e J r If attorney: Name and relationship of your client to persons whose marriage record is required. Sign? of Applicant ~~ Ac:;e7~A:~cz ~d ft(3Li Fd~ r )7!(C~/S/~ IV Y (2-, 01 DOH-301 (3/93) Date Please print name nd address where record is to be sent. E DWf\Rd F !3p-ow l.J h ~ \ 5'); eAfe f),2J f=! ( 3 Y IV) e (PLEASE SEE REVERSE SIDE) .. ~cJ/ ~ 10: 195 057 365 CLASS D. BROWN,EDWARD,F 821 SHEAFE RD NO 134 eqUoHKEEPSIE NY 12801 Dol: 02-12~ SEX: M EYES: Bl HT: 5-05 E: NONE R: NONE ISSUED: 01-12-06 EXPIRES: 02-12-14 ~28P3850 .. Application to Town/City Clerk for COe>' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section 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 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. PLEASE PRINT OR TYPE Name (First) of Groom rr-- Groom's Age or Date of Birth Residence of Groom S Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) (Last) 9 v..~'" ~ .... e>t (County) (State) U~\l (21 'ISO Name of Bride ~L-~ Bride's Age or Date of Birth ,O...e-c t.q I q "3 t.;' Residence (County) of Bride t- If Bride Previously Married, State Name --- Used at That Time \ <-..... -"'--"'- "-c- Place Where Marriage Was n "\ Performed 0-1 (First) (Middle) (Last) 2. ............--\..l._ . u~ \1.- (State) rzJ u....~- yY\ r C.....,t l.......t c~-^ ~ For what purpose is information required? -\- L' Co-- \ l ~( s:;:: .:--e.-J What is your relationship to person whose record is requested? If self, state "self." S; -c.s. v-v' In what capacity are you acting? , . s ~'-(' s; .&L \ ~ If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant .- Date Address of Applicant /C~ .J.OCJl Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) .. , . Application to Town/City Clerk for COe}' of Marriage Reco,rd NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and D Fee $1 Search and ~ Fee $1 0.00 Certification 0.00 Certified Copy 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. PLEASE PRINT 0 R TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of f\ Sd\6 of ~ .. t{ ~C\) Groom \1\. \ cXlu.e \ n e ( Bride Clch .{:. \ ~ e. I. n c: (' Groom's Age Bride's Age or Date of ~b \ \ \ \ \C\'I 0 or Date of \:)O\?:::. "d-\ ~ 0 \ C; ., D Birth Birth \ \ Residence (County) (State) Residence (County) (State) of -- ~ ~'1 O{\~ of ~ \c.\J-€=~S ~ '-lor Groom \.~ U..\ CY\-e~ "".':) -e Bride e --u I ~ Date of Marriage If Bride Previously or Period Covered Clu.qu.~-\ L.. \ \SC1. ~ Married, State Name by Search , Used at That Time Place Where Place Where \-.\.u.. ":::1::.:..-\1 ~\ \\ e. License Was--:- ~ \\J (' Marriage Was '~~ . Issued \ bL.,..) \"1 u-p(J \ r<J..-e Performed ~V6~C:,(\ Cv-I-- For what purpose IS information required? What IS your relationship to person whose record is requested? - ....J-\f::::L \., 'I G..f('""')L ~ \J rfD<'~e ~-I If self, state "self." ~ \~ u c.. ~0G\:::s:."nol~ I ~ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. ."'. f APPlicant~, \ Date ~LC\U~ F "\-- 1 ~ O-t~~o /C_"-.c,- ~/l :24 \ -:?Col '0ufAPP~ ~ Please print name and address where record is to be sent. , ~Ln Sc.. he.. ~ coG\ t"1 \. " -e.. -e.. \ V\~ r 1 \ ..~~~'" , <L~-\=C--" \~ \S'\ ~<o \ S C;,\ \ \-;)C( ~ 'J) 'fl.\! e \-k..\ C\. ( \. 2- S ~cu.... ~c.....( ,-'-.., \..)'\ \ 2-S~'6 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) 1F'~~~ !l AU~ 9 2007 ~ B Y: ______~itJ.t-r't_ To whom it may concern, ...J I Rachel Scheiner am requesting a copy of my Marriage Certificate. I was married August 21, 1993. ti/~ DENNIS CONN 0tarY Public. State of New Vork , No.01C04787853 Qualified in Dutchess County ...... ~ CJ. Commission Expires November 30. ~ ....." ....I . .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . Application to Town/City Clerk for COE!)' of Marriage Record Search and D Fee $1 Search and 0 Fee $1 Certification 0.00 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. .:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:........:.:.:.........:.:...:.......:.:.....:.....:.:...:.p......:....:.:.:.&........r..............:.:.:.................:.S........:......:.....:.:..:.....:.11....:....0.......:.:.:..........:&.......:......:....m.............:.................S........:.:.:.:.:.:.:.:.:-:-:-:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:-:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: ::::::::::::::::~:~:::::~:~:::::::::::~:::::::::::::~:~:~~:::::::::~~:::::~::::~::::~:::::~::::::::::::::::I:::::::~:~::::::::::::::::::::~::::L::~:~~::~::::...:.::::::::::::::::::;i::::::,:~:::::::::::::::.:.:...:::.i:~~:.}:::.:.:.:\./g:::Li:::::::::;:j:.......::::.:::t::i:::;::.~::.:::.::::::;:::~.::::..:L.:.:::.:::::.:::.:J.::::~:~fii::.:.:.:::::::::~:::::::::::I:::::::::::::::::::I::::::::::::::::::~::::::::::::::::~:::::::::::::::::::::::::~::::::~::~:::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) ~room KOY\l( lcl Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) (Last) 5u..1 .ty- l- 3'18/5Q (State) ..0ib Name (First) (Middle) of M Bride ClV Bride's Age or Date of Birth Residence (County) of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (State) For what purpose is information req\Jired? ~Lt:LP Ln~ In what capacity are you acting? What is your relationship to person whose record is requested? If self, state "self." iLt-t). . t) 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 sent. f) . 1It11l1,n t) f ~rSDlp \0 (PLEASE SEE REVERSE SIDE) Application to Town/City Clerk for Co~ of Marriage Record ':':'[[:::'::;[:::;I,;.).::i;;::'!i:i.:!';::";!.;f;i81::8:;..I:::_III:::_;.1,;I:i:][:!!::;!['1;::I:;;::;.:i;::.!,:.;;:::)'!::";':,!'.;.':';:);;;::;I::;:::';;.'it;:'!,.:,;:;:::,::!' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section tT\{:rw//". ..:' ....,... :-;.:.;.:-:.:::::-:::-:. ...-........ Search and Certified Copy Search and ~ 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. O Fee$10.00 per copy A Certified Transcnpt 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. PLEASE PRINT OR TYPE Name (First) of I Groom ~ e. ct I e... Groom's Age IV or Date of O. I Birth V, Residence (County) ofj) I' Groom j, ~5 Date of Marriage IV or Period Covered () . / I I 7 ~ / b Search Y Place Where I. I V \ / ~~:ewas W I+ft'tV 1.1t5;' . 1 (Middle) R. S I /7 '15 ( Last) -VEN5UlJ For ~at purpose On;rm~:: :(ired?flu reo ~ .~f-.. --t tJ I f1 ;) +e S ~f In what capacity are you acting? ~ ~'I 5"2- DOH.301 (3/93) Name of / 'r _ Bride E: c: t.,- Bride's Age or Date of Birth Residence of ( Bride vr If Bride Previously Married, State Name Used at That Time Place Where Marriage Was /AJ Performed (Middle) ["Ll{SON (Last) LLEN If 1ft (State) N- et 41 t'./\J I NI !) e, f., ~2 (County) c...h.e5S Xe/Ve What is your relationship to pers.on wh~ record is requested? If self, state .self.. S' e I-r- If attorney: Name and relationship of your client to persons whose marriage record is required. Please pnnt nam f~O. LON 2f'l51:. (PLEASE SEE REVERSE SIDE) August 7, 2007 To Whom it May Concern: Please send me two (2) certified copies of the marriage registration for Freddie R. Stevenson and Renee Ellison-Allen married on November 1, 1991. Enclosed you will find a copy of the original certificate. We need copies with the state seal. Also enclosed is a check for $20 to cover the cost of copies and aretum prepaid over night envelop. Thank You C-7A)C,2~J cJ~h~ Renee Stevenson IJII ,- ,.. : ; -'" .; '," i'iI t ~ " '" . < > I ~ '\ .. , , '" < , ~ "' ........ 11'-,.. ~...._ OAf.SA UCENSE 29166410 ....c ~, 1t!llRr', 1 iIIt.ted: 03-22...,.", ' , ',. ".... F "' ........ ~,' BRO h'ttr: ,,' . t hlrtt"i". ~_6~-S~, ", .', 12.221948 ~~ ", , ~ llJJ " _ .: !II; I .. . . August 7, 2007 To Whotnit ~y Conaml: Please send me two (2) certified copies of the marriage registration for Freddie R~ Stevenson and Renee Ellison-Allen married on November 1:> 1991. Enclosed you 'WiU find a copy of the original certificate. Weneedeopies with thf: ;tate seal. Also enclOSed is a oheckforS20 to rover the cost of copies aDd aretum prepaid lver night~velop ~. ..--~-"''''\..-..-'~- ..~. ... ~' . ,;:-..... ......""-- ~~.:: ,i~ J -. ~- .. -...~~... --...., .;,,'.,.. .....~::'-......-;.,;. '~ - '0''' ~;. OJ' ~ -~. ~~ :.....,a .'" ::;: =:: -.-;: ~ ....0.:- ..:....._= t !.:; .".. - -r ~-- :::; -- - ........:. ~~..: -..' .~ -- ~~~ - .:' ~.. r., "".:,-,,~ ":.. ~ .- .... ,J' .~...." ." ThankYQU ~,{4~ --- Renee Steve.nsQn -. . - -. .. -' - ~.- ~~, ,~ i:~~~~'. ::"~i::i'. .,;,...;,.....=.-.....'....',/ l DJI~"",,"~ ". ._.__ . ..~~if'"'.".'..: ~,.;_nl.;.;'~~' ".~~,Qr. ~;".,~." ;... ~:""~'\,:i.l:~~:}~..: ." .. . . .' Y'. -:!'.".. .': ,. . . r: ; :: , . I ", ~" . r :-. - 1 d L.JdB17 : so 17L7i0c 51 . I n .f 17c1717L8G015 : 'ON X~~ : L~Od~ " D X Z ,0 ,:~~8 '<~~t~!~;~r~;~ .4~' '- t:1~~,f~~~~) ,,.." (~ >= I\) ISJ I\) ISJ iSl ".(:. ...-" "~ .~ --- -.'. . ;.,".--:..- :1.~', " ~-"fc""-""""""" "_~;..-;-'t::-~~;,~:. ' I-"- ,~ 3: "..~LAiNJ.:"_F;:;~~stittt:'" S;C;::RETAAt(f)F STATE -" ".~ .-0 I-"- '.. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Col!}' of Marriage Record Search and D Fee $1 Search and M Fee $10.00 Certification 0.00 Certified Copy 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 occurnng 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. :::::::::::::::j::::::::jj:::j:::::::j:j:::j::::::j::::::::::j::::j:::::::jjjj::::jjjj:j:::::::jjjjj::::j::jj:j::::j:j::::j::jj:jj:::::::::::j:jjjjljllll.:::11I11IIljj:jllll::::llljjjlllljj:III::jjj:jjj:j:j:jjjjjjjjjjjjjj:jjjjjjjjj::jj:m:jj:jj:::::::::::j::::::j::::jjjj:j:::::::::::::j:j:jjjjjjjj:jjjjjjjjjj:j:jjjjjjjjjjjjj::jjjjjjj::j:::: PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) (Last) -A'2IvI ts\' Q.o ThQrv'/AS -=+\ (State) ~ 05 \u~P \~ ~S (First) (Middle) (Last) Name of Bride ~~ Bride's Age or Date of Birth Residence of Bride Do~\~ ~ If Bride Previously Mprried, State Name Used at That Time Place Where Marriage Was "::> Performed S\. MAR-,- --::t- I S- 5 z;- (County) (State) ~ l~''r-\ ~\ L L For what purpose is information required? NA-tAE. ( l D ~~ . A;i' WDR.1LJ In what capacity are you acting? What is your relationship to person whose record is requested? If self, state ",self. II ~c::- If attorney: Name and relationship of your client to persons whose marriage record is required. A pile nt 3"':\ \{f'l~~ ~'~ ()L-EJ'--..~ ~'" u... ~ N '-\ I 29cf't DOH-301 (3/93) Date (3 a ':t- Please print name and address where record is to be sent. S .~'7.At-i P.o.IM~~ ~"::>lLC p.e...rv\ ::>\i2..0I-l~ \'\N: \L<;;:I/ (PLEASE SEE REVERSE SIDE) , "--------~~ Application to Town/City Clerk for. COe.)' of Marriage Record " NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and Certification Fee $10.00 r 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 A Certified Transcript includes all 0 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. ::::::::::::::::::~::~~::::::::::::::::~::::::::::::::::::::::::::::j:j:::::~:~~~~:::::::::::::::::::::::::::j:::::::j:::::::::~:~:~:::::::::::~:::I.j_I~::I.Iw..g::::BIII::::III::::I:_lljj:.IE::::~:::::::::::::::::::::~:::~:~~::~~::::~::~::::::::::::::::::::~:::::::::::::::::::::::::::j:::::j::j::::~j::jj::~::::::::::::::::::::::;:::::::: PLEASE PRINT OR TYPE Name (First) of Groom 'tV,' {t.. . A 1'1 Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) (Last) R Ef./ft'1Z c 1//tJ,/r7 (State) N('w (/ It! c.. (County) f)(//(M5 S ? lit; 06 Wf/;J;t<{1ti'V tl(/M (First) (Middle) t. ?,/Z) Jt, 7 (~~/L)f.D fit! I I . .~ 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 Marriage Was Performed ~ L. f/t-". (County) D/rc/fLsJ (State) /llt'a/ (j tl-/t:. /FtJIJ rtr /t?rl/l q,r /V For what purpose is information required? P rJ tt;tA fC- a; f1 In what cap-acity are you acting? . S'CLP What is your relationship to person whose record is requested? If self state "self." , r"'~ ...r If attorney: Name and relationship of your client to persons whose marriage record is required. IJ //1- DOH-301 (3/93) Date '/7/tJ 7 Please print name and address where record is to be sent. CE\\fI-' J AUG 0 1 2007 TOWN CLERK (PLEASE SEE REVERSE SIDE) # .. Application to Town/City Clerk for Coe,y of 'Marriage Record NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section ::::::::::::::::::::::::::::::i:i:i:i::::::.:,i:i:ii:::::::,:::,:::::::::ii::::::::::::::i:::::i:::ii:i:i:i:::::i:i:i:iiii:ii::::iiii:i::::::::!::::::::::::lIlg:ii8::::I:lllIil:::llllllii::IIIIII:::.l:::::::::::::::::i::i:::::::::::::i::i::::::::::::::i:i:iii:i:::::::::::::::::::::::::::::::::::i:i:::::::::::::::::::::::::::::i::::::::::::::::::::::::::: Search and D Fee $1 Search and [X] Fee $1 Certification 0.00 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 marnage. 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 marnage occurred. proceedings, or settlement of an estate. :::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:::i::::'::::::::::::::::::::::i::::::i:i:i:::i::i:::::::::::::::::::::::::i:ii::::i:::::II1:..:::I.II.R::::IISI::::IIIInlll:::rnll:::::::::::ii:::::::::::::::::::::i::::::::::::::::::::::::::::::::::::::::i:iii:ii::i:i:i:::::::::::::::::::::i::i::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of M I R. 0 S~ A (,J tZr M rv 'f of H A L l f\) A is LV 11 Z{ ~ N'f Groom Bride Groom's Age Bride's Age or Date of 0 21 0 2/ (3 , or Date of 0 <6 ) 0 L( )'59 Birth Birth Residence (County) (State) Residence (County) (State) of 1) LJ TCt-f E s s N t LV 'fo RLt of 'J) LlT d{ ~ S S (\)EUJ 'fo Rt( Groom Bride Date of Marriage l 10 If Bride Previously or Period Covered 0 2 2 '3 7 Married, State Name by Search Used at That Time Place Where Place Where License Was'O fA) N 0+ LV A P P I }J GE:, R. Marriage Was '10 lP r\) Of U)f)PP l ~ &'ER- Issued Performed For what purpose 15 information required? What is your relationship to person whose record IS requested? If self, state "self." In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marnage record is required. Sign~;can~dY'~/ Date Address of Applicant Please print name and address where record IS to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) .,. ........... ~ ,NEW YORK STATE DEPARTMENT OF: HE~LTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and 0 $1 Search and 0 Fee $1 0.00 Certification Fee 0.00 Certified Copy 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 occurnng on the original record of the marnage. 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 Qf an estate. Ifself,state"self." ~~rJ. PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage f _ \ "A C\ c- or Period Covered W- J ~ <:l- by Search Place Where Ucense Was Issued (Middle) (Last) 5- (State) (County) pr- { c.::e rrt- -In what capacity are you acting? (First) (Middle) (Last) Name of Bride Bride's Age or Date of Birth Residence. of Bride If Bri?e Previously U - l 3 - OJ <6 Marned, State Name Used at That Time Place Where .Marriage Was .-r:; Performed ll. rdD~l (County) (State) - pV"~ senf If attorney: Name and relationship of your client to persons whose marriage record is required. Signatur ApRlica Date DOH-301 (3/93) e and address where record is to be sent. (PLEASE SEE REVERSE SIDE) " .,. . --------. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record Search and D Fee $1 0.00 Search and ~ $1 Certification Certified Copy Fee 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. ::::::::::::::::j::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::_I:::IIIBIIII::::1111:::111::::1:111:::111::::::::::::::::::::::::::::::::::::::::::::1::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (State) N Name (First) of Bride Bride's Age or Date of Birth Residence of Bride If Bride Previously M~rried, State Name Used at That Time Place Where Marriage Was Performed (State) N In 0 h capac;;;f'" ;;:;/7 h.dul j- What is your relationship to person whose record is requested? " se". state "sell," IR% ' If attorney: Name and relationship of your client to persons whose marriage record is required. Date 07 Q7 0-7 Please print name and address where record is to be sent. Jt4 '7/ if j() (j 1)'\ l5Y} L ----- (PLEASE SEE REVERSE SIDE) ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of .Marria e Record Search and 0 Fee $1 Search and 0 Fee $1 0.00 Certification 0.00 Certified Copy 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. PLEASE PRINT OR TYPE Name (First) (Middle) ~room fYI{' ~ I Groom's Age or Date of Birth Residence of Groom J Date of Marriage or Period Covered by Search Place Where License Was Issued (Last) ...."... c..o t1 (State) 11 S' (Middle) (Last) FJ-o ~r> 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 Marriage Was Performed ..- ~tif ,J C/_L(- [(9 (County) ~ (State) <-(l .s. ---- For what purpose is information required? In what capacity are you acting? .--t.J~ J ~ What is your relationship to person whose record is requested? If self, state IIself.~'.x11 ,~ If attorney: Name and relationship of your client to persons whose marriage record is required. Date {d.. S-qtJ DOH-301 (3/93) Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) ~ - - ------------------ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe}' of Marriage Record Search and D Fee $1 0.00 Search and ~ $1 Certification Certified Copy Fee 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. ::::::::::::::1:::::::::::::::::1:1:::::::::::::::::::::::::::::::::::::::::::::::1:::::::::::::::::::::::::::::::::'::::::::::::::::::::::::::::::11111;:::.11..::::11111:::111:::8:.11:::1;1:::::::::::::::::::::::::::::::::::::::::j:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::'::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) (Middle) of '"T Groom r tJL..e- '--lOl...LtS Groom's Age or Date of I :J - I () ~ '} 2) Birth I Residence of Groom &z::.~I\.k) lC 4 Date of Marriage or Period Covered by Search Place Where License Was Issued (Last) (\) 6\~es (State) C-~ ll//;;)/OO ~pp,,!,-~~ Lcj{a)~ N6[L (County) Name (First) (Middle) ~fride ~l~ -L- J-.{O.J. sf- Bride's Age o~Dateof t- I C:.~ 70 Birth Residence (County) of 1\ _ i Bride {I..:JU+L-lA..~s. 'S.. If Bride Previously Married, State Name Used at That Time Place Where 8.. ~ Marriage Was Performed lc (Last) Wt'lSc~ (State) tJ For what purpose is information required? (l_L6J\~ 6 ~ ~-t-s. In what capacity are you acting? 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. ~ ? Please print name and address where record is to be sent. Lx- \) \'~-L ~1~f(JIl}{6iLr (3, poftd ~\LL L~_ ~tcLJ\ ~~. ,1fIDS~~ . r, -i 1\1.:1 ,. . (PLEASE SEE REVERSE SIDE) - .;:;JJ3C:l ....... ? ess of Applicant /3 ~C>f\d k/LL ~ ~/dO\ I ;J.y. (QC~G:, DOH-301 (3/93) Date ~ r:;) r- 6; .. -----------~ NEW YORK .~T ATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record " Search and D Fee $1 0.00 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. PLEASE PRINT OR TYPE Name (First) (Middle) of Groom \)Q(Y) C Groom's Age or Date of Birth 02- Residence of Groom v'\- h ~ .r Date of Marriage or Period Covered by Search Sv\ Place Where Ucense Was Issued (Last) Name (First) (Middle) of Bride LC\..uc C- Bride's Age or Date of Birth Residence of Bride U ~ If Bride Previously Married, State Name Used at That Time Place Where . Marriage Was Performed (Last) SY'Y> (State) . (State) U For what purpose is information required? 1J'0~~) ~r- 'T12.\~ ~ ~co.rdS What is your relationship to person whose record is requested? If s~r-felf.1I In what capacity are you acting?- (0,ro'NJ - If attorney: Name and relationship of your client to persons whose marriage record is required. Date ~...\~- Please print name and address where record is to be sent. L-~ ) Apt 120Y jClvo(J DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) ~"- Application to Town/City Clerk for Col!}' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . Search and 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. :::::::::::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::~:::::::::::IUI.I:::I.lm.1::::1111::::111:::1111:::911::::::::::::::::::::::::::::::::::::::::::~~:::::::::::::::::::::::::::::::::::::::::::::::~:~~:::::::::::::::::::::::::::::~:::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered '1 _ ") '2 -- 05 by Search ~ v Place Where Ucense Was ..-.- Issued \ ()WVl of- \)J", (Middle) (Last) .\ :n: W1L p ~'--;;{a-15 (State) (County) D Name (First) ~fride tv\ l C ~e \ \e Bride's Age or Date of Birth Residence. of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was cL Performed (71. (Middle) (Last) ~~ M 1s---1L, (p (County) (State) DLAk\.e<&~ "'I t~ (. ~ vft~ \.Ab.ff~ ~er)' What is your relationship to person whose record is requested? If self, state .self." For what purpose is information required? ~{l.Q^0)\T In what capacity are you acting? Self If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant <-.~ \J.-- Address of Applicant (p () tb.:f= r not- ~ l U.\oV1)O IL id ~ \L6LfS- DOH-301 (3/93) Date , J C\ OJ Please print name and address where record is to be sent. IF'~d1~ Jl JUL 0 9 2007 ) BY:. · (PLEASE SEE REVERSE SIDE) -~ -iF It; ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and D Fee $1 0.00 Search and 0 Fee $1 0.00 Certification Certified Copy 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. PLEASE PRINT OR TYPE Name (First) (Middle) of :JOst ph C!. Groom I Groom's Age or Date of Birth Residence (County) of Groom Date of Marriage or Period Covered by Search Place Where tV II f P /n C)1f Il.. fI; Ucense Was Issued (State) Name of Bride ~ride's Age "7/"" .t:! 1/ q 63 or Date of "/ if-O/' Birth I. ,,'--j;;kL.5 Residence / j , (County) of. .%J't:ltPl1kll~k ,1V.E. Bride W~ 1He: It.. - If Bride Previously A ? ;\\ Married, State Name IV l./ Used at That Time Place Where ,. 1:// _ r / ')~p 0.1. Marriage Was U;il~1E.. ~ ~#ffJH / "-1"#/1 oJ Performed IV., 4-rf./o C J,? , (First) p~[I?':7€. (Middle) J) (Last) 16 1TEtU (Last) -}{ t9 B c:.. (State) tV.j , For what purpose is information required? What is your relationshi to person whose record is requested? If self, state "self." ,,' ;,. In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date Jinl1lC ~ <fJ ~(J~7. Please print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) . --------. '- Application to Town/City Clerk for COe>' of Marriage Record NEWYOR~ ~TATE DEPARTMENT OF HEALTH Vital Records Section 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 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. PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of C ./ Groom ~ Date of Marriage or Period Covered f\ r 5 I (j)f (j"f fa by Search V - - 1.., l ~~~~s~v:~: JJJA ADJO~tJ[G{L rPL $, Issued ()J'I" T ,- j (Last) ({)LA 65 (State) Name (First) 'U (Middle) ~fride It Pfl.JpflG Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (Last) eA HOJ - /- ,Q{'6 (County) . (State) For what purpose is information required? e6 ('02-0 In what capacity are you acting? 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. Signature of Applicant Date 2- C( 6D 125)\ 'fy:y DOH-301 (3/93) 0- ~ (~ 0 Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) -----'~ Application to Town/City Clerk for COe>' of Marriage Reco.rd NEW YORK 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. Search and Certified Copy r:;(' Fee $10.00 . ~ per copy 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 settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Last) Name (First) (Middle) (Last) of (/"1r of Groom .J.../ I c. . Bride ee Gr00m's Age )/j Bride's Age / 2~ / f3 / or Date of 7 / or Date of I / Birth Birth Residence (County) Nt7 Residence (County) (State) of 1 of ~\ Groom O--lbS Bride ::t'Z:>S Date of Marriage :i/1) /0 G If Bride Previously or Period Covered Married, State Name by Search Used at That Time Place Where Place Where Ucense Was fh //> Marriage Was Issued <(, J Performed F~'r'~~i"p~~p~~~'i~'i~f~~~ati~n ~equired? What is your relationship to person whose record is requested? If self, state "self." . /1W\1"'''r/Pf f/oy? Sr:I,r::. In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant ~~ Address of Applicant {J .ftf..( /I .f- Tr'"'f: ;, r r'" I). /I i (""''t! Dr.'v--( frC1I'f'//l,?-{yj ~-((I) / DOH-301 (3/93) Date flcJ6/& II-r' j. --H C fl/r /.) J~ 0 Please print name and address where record is to be sent. S q "'^ -r: ~ (PLEASE SEE REVERSE SIDE) . -~'- (845)298-1478 TO: 17193902955 P.l Application to Town/City Clerk for CoeY of Marriage Record EDWARDH 'SOiiMERFIE~D ~~.g:'7 . r.., -,~__. n-!'/- -- <Cba~-r:(€~ i ~ T-F'.Q, Fee$10.00 .' 'Vv J 'n E 'Pi t5 4') C 0 I)8r copy . , ;, ~'t+:> \) l-J "\.~ q ) 0 )rd issued , ...._.... "'_'___ w1e 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. Search and Certified Copy ~ Fee $10.00. t.a per copy A Certified Transcript includes all of the items of intom1ation occurring on the original record of the marriage. A Certification may be used as proof that a marriage occurred. A Certified TranscriJi.t 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. PLEASE PRINT OR TYPE Name (First) of E Groom Groom's Age or Date of Birth . Residence of Groom Date of Marriage ~r ~:~hCovered M 1\ t I I q 13 P.lsce Wh~re ~ W J.J (!)..t= Ucense Was It Issued W APf)/ tJ G t=.1l.. (Middle) (Last) 50 c:::ll MM~rJe (State) , ~. For what purpose is information required? To. Dl5fA/)j rn) L t1l\f-Y j:'J) -'::"0 t\ 5 0\ ~ A JJ - In what capacity are you acting? HlJ<SR>J\ A J 1) What is your relationship to person M10se record is requested? If self. state "self." 3 E: z r:. If attorney: Name and relationship of your client to persons wtlose marriage record is required. AOdress of ,\pplicon ~ .-' /;'10 3P> FJ L,bIAJ~ IEllIlA05 lV ':bE~/EL)::) Co o o DOH-301 (3/93) .... of Cocc>P-A \::)C) CountY of Bl-- VA~ Subscribed to and Sworn before me "'I ~ day Of\.JuN ~ 20 52..1- ~:t~.e/u\. 0 ~ ~ ~ Notary Pub J RECE\"'" JUN 2 5 2007 TOWN CLERK ; ~, :;._........H. , NEW YORK STATE DEPARTMENT O~ HEALTH Vital Records Section . Application to Town/City Clerk for Co of Marria e Record Search and D Fee $1 Search and ~$10.00 Certification 0.00 Certified Copy 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. PLEASE PRINT OR TYPE Name (First) (Last) Name ~ ~ Groom t:'\ Bride Groom's Age Bride's Age ~~ateof cr -((-57 ~~ateof 0 -rz -S~ Residence (County) . C (State) Residence (County) /l (State) of ---r-") ,~\' D<.. (U- of I l '- 0 ' iA \ Groom V~ c.. t\.e'} '> Bride - 'iC '^-.€ 5> S I ....., - Date of Marriage If Bride Previously or Period Covered Married, State Name by Search Used at That Time Place Where Place Where License Was G(I" C Marriage Was Issued ,I~ Performed -eU- . For what purpose is information required? In What is your relationship to person whose record is requested? If self, state "self." fII\ y ~.Q 1-,:::. If attorney: Name and relationship of your client to persons whose marriage record is required. Address of DOH-301 (3/93) Date -Z7-0 Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) . Name o~ Bride Bride's Age or Date o~ Birth Residence o~ Bride lo\ '5 - ~ I~ Bride previously Married. state Name used at That lime Place Where Marriage Was For "",at p,,,pose is inton"""on reQu<red'! · ,~ " I~ sel~, state Se,!. ," \-av~' i)- It attorney'. Name and relationsr \n .... capaciIV are yOU acting'? - rn"",age record is reQ" ~ --------- , ~ I.f) (V') (V') o ~ III ~ ~ o o <l' I.Cl N ~ ... ~O~ CJ oC( ~ ~Z 0>- ~_o:::> ~Q.:I:~ ..J~cnz (,)~ ~ - ~uJcn Zu.-d 300oC( o ou.. 1-% ~cn 30 0 ffi NC) .... Z a: ~ ~ )(. :r; U ~ '1! q ~O :: HEALTH , r\J\i fee $'\0.00 ~ per copy . I marriage record isSued lent, includes the names ot ~e at the time the bcense ~ ot birth ot the bride and search and certitied copy Dot that a marriage occurred. " certified T raoscript rnay "" needed "",ere proot 01 paren",ge and certain other detailed ,~torrna""n rn~ be required sUCh as: passPorlS. veleran 5 ""neii"" court p<Oceedi0g5. or semement 01 an esl8le. ~ . {Last) :lIe) {Last) {first) \ e ( oo.-Q {State) , ~'V ~ ~ ::a 0 >- w <<: U 0- Z <fJ '5 :f <<: r-- <ll {State) ~e.., ~CA S; QlJ€ll lYiCI). '/f'J( ) ~ AddresS ot ~plicant l\ Lo \ S . \L e (y,Cz,L'Yl t'\~ ~ " I --- '. ~ (>G'^-jfcW \-<J_V) 1 N 'J 00H-30'\ {3/93) Please print' /) ~~Al 8~ \tJ l) C\O {PLEASE SEE R8IER~" "' J" i' MRY-29-2007 08:13R FR[~:TOWN CLERK c :345 ~) 2131::; - 1478 Tel: U:::1 '::,;':364'323 P.l ~~::\\@\~~~:~\;!ii~i~lt:j:~~j~~@!f!~1!f::~~it~:~i!!~!~:~:~~j~:~iil~:!i.:~!t~!immll~llj!la:I~II:g~:llt: NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and Certification "tv1' 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 A Certified Transcript may be needed where proof of groom. 1 parentage and certain ott;ler detailed Information may be required such as: passp~;t~. veteran's benefits, court A Certification may be used as proof that a marriage occurr:,~ :~~~:dings.or settlem~J:f_~~~sta~~__.___ 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. :j*!~li~!1!t11*:;:~!1:M~wl~:!:~!;:~~!m~~:i~rm~l~]ill~!~:~::l\l~jl:.I:"::::::;:::::']JI;lliletfllll:~.II:~I.1.:ll:III::fi;::!1::*~~!~::~:ij:::!:lj:;it:l:~:ji:!ii:~iii~~1i;m1:;:1:~:I:~:;:~ji~i~!i1;i:;:i;:jt:'i:: PLEASE PRINT OR TYPE Name (First) of ..- Groom ~o U:,..> Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where ""1" 0 ....... N (!.f W?l fP \-n ') e...< ":> UcenseWas l)u'l,-I~ f.. S.~ c.o-..)(')"J"\ Issued I (Middle) (Last) Name (First) of C- Co ({rf'A ~ Bride '{V\{>rvfZ- 'iztJ Bride's Age or Date of Birth Residence of Bride If Bride Previously Married. State Name Used at That Time Place Where Marriage WBb Performed 'f 0 v & "" (Middle) (Last) PrtJ IJ C L A \..A,j ~o sV ? A-'i' (Z. ,c....~ i.tq. ~ (County) 'S-s-~'~ (State) (County) (State) L..A- c..-A l-A C-.A- 1 O. I $ - '2-0() CJ -3"ACcJ~~~ ~;(I l 7; '\t\e....( to",^- ~ 0 {\ .. ::"~:";":':'::.::(:ii~1:!H:::::l:!11::1ifuRiili::~lil::~:i~ii\i:~:ii:~:::::illj~f:ti!Hj~i:i::;:~~t:~~~~:t:ll~,~t~:~j\!~~!j::~j:fimi:j:::~i::ii:j:!::i::;;i::;::j;:tl:::::~!\;ji::~:1.ill:iill~:\;:i:1~:~~:~:\::!;:~~::~i::l:l: What is your relationship to person whose record is requested? If self. state "self." S E-l~' For what purpose is information required? _-1Le-o-\ -\-'v-.. l~ Su 0( Ct..t\ '-e.. In what capacity are you acting? W \ ~ ~~ If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant ~ Address of Applicant ~ei...\.~ \-\AC.t.L-TI~L \J~\.\~~ G\e.{\ I CPr :.;:;:::?::.::::~~r~~:~~:~;;:~;f,ilir~[:li:'~l:!!:~i:~:;:~~~:;::~~:!I:t1:*~ ~r~:1:~jliit1;1:![!~!~:r~!l~l!~~r::!~1:~:~*!i::l:" .. . A-Vt- ~ ~ q,yO\ ~ - 2. - O---r Please print name and address where record is to be sent. -::i 0 ~ ~ t lV'l A \.)~~ E-l'-l '(V\ c-Lo (Z.. (\1"1 A c...-~ 5S 1.\ S\4 A "l. SL-4' ,~cz. A\1 i... -&-- ~ \1A-L.L.f.'1 G-L~IJ CA q I Yo I DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) CALlFORNIA ALL-PURPOSE ACKNOWLEDGMENT County of On personally appeared ~onally known to me 15 . proved to me on the basis of satisfactory evidence Jill MARIA NAPOLITANO 'I~'"'., Commission II 1489821 ~ i ... ~. Notary Public . California ~ j . . . Los Angeles County ~ __ ~ __ ~~~~_~1~2 to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/shelthey executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or th entity upon behalf of which the person(s) ct ,executed the instrument. OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. 1 Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer Signer's Name: r'\G\0r~ 0\ce-af""PC-K . Top of thumb here ~ndividual D Corporate Officer - Title(s): D Partner - D Limited D General D Attorney-in-Fact D Trustee D Guardian or Conservator D Other: Signer Is Representing: @ 1999 National Notary Association' 9350 De $oto Ave., P.O. Box 2402. Chatsworth, CA 91313-2402. www.nationalnotary.org Prod. No. 5907 Reorder: Call Toll-Free 1-800-876-6827 \.W1Jlc..Q 161~ 662 M fD/ffI ~< 0118< CALIFORNIA rBlV DRIVE CLASS:c HAIR:SRH NT: 128 -C.~.__."..'.'~_'~.".~ .._ J'~,{$lI_~,~~ ..:..... ~~, ,n Application to Town/City Clerk for Col!}' of Marriage Record .. NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section 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 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. TOWN CLERK PLEASE PRINT OR TYPE Name (First) ~room f(~~ fh Groom's Age or Date of ?: Birth () Residence (County) ~room lJuJ-C S'S- Date of Marriage or Period Covered' by Search Place Where Ucense W Issued hK pMu;?on~L In what capacity are you acting? Wlt Name of Bride Bride's Age or Date of Birth Residence of ,.J.. ., Bride ()....f If Bride Previously M~rried, State Name Used at That Time Place Where A Marriage Was 0 Performed What is your relationship to person whose record is requested? o seO, stale ...0.. ;() oR J.f If attorney: Name and relationship of your client to persons whose marriage record is required. DOH-301 (3/93) Date (PLEASE SEE REVERSE SIDE) ~ --~~ .'" -. Application to Town/City Clerk for Co of Marria e Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and D Fee $1 0.00 Search and ~ 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. PLEASE PRINT OR TYPE Name (First) of "l'- Groom '.J Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (State) (Last) Name (First) v:e l,L'Y , JR . ~fride A ('(\ R tJfV\ K I ~ ~ 5+cr ~!~~~~e Lf l [) ~ ) b5 Residence (County) ~fride I).A~YVSS; (0. If Bride Previously Married, State Name Used at That Time Place Where I Marriage Was "j^W vi I 1 VA np . Performed I U v~~ , (Middle) (Last) (Middle) RIU1A t2.t) q I [) i ( b/A (County) ~hlSS { () " IV'! J u V\e '1 J I q t; d-- f(Jwn! WOfP. (State) f'J\ For what purpose is information required? L i (f41 S( (ff'l/;UU fA L What is your relationship to person whose record is requested? If self, state "self." y (f In ~+ are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date b /) :5 / ()q Address of Appli t 10 oeFoR-D L Y fV'\R / fV+r Please print name and address where record is to be sent. 120 o s-:t-t;g DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) IGu~ ;;1 B Y: ............!f.~~~. .. ~ . ~te/~ ." Application to Town/City Clerk for Co of Marria e Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and 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. PLEASE PRINT OR TYPE Name (First) ~room U,50 1'1 Groom's Age or Date of Birth Residence of . Groom l't Date of Marriage or Period Covered by Search Place Where Ucense Was \; I Issued VV (Middle) dO (State) N~ (County) (Middle) F (Last) 0A-VV -C Y' Name (First) r ~fride j;; I f -e -{ J Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where I Marriage Was ~ 0 il-( \A,..02. t I R -e F (If >>1 C k U. ;r~"\ Performed r, - . ;)0 (County) b J'tGLx s s (State) t\J \ -~- ~ --- .----- -~~. -- ..... ""-- - .-. - -.--' In what capacity are you acting? .I.(,_U~~.~_<-_{t_ C ~:} \.j . I ress of pplicant 7 0 :~L/ Ht L j f' ~ 71-/ ct 7 · LA4f' /01 T tJ IJ (' ,) 'cf J. r}& DOH-301 (3/93) What is your relationship to person whose record is requested? If self, state "self." . " :'\-c. . If attorney: Name and relationship of your client to persons whose marriage record is required. Date ~/I lOt Please print name and address where record is to be sent. 12//...-eeJ . 73ohIIIV1~'0 7c,}..Lj lltL J r€ rt, er- e IlAf' i ()'f-~ ..P N ~. (1- '(' ,). d- 0 RECEJVFI J JUN - 7 2007 (PLEASE SEE REVERSE SIDE) TOWN CLERK June 3, 2007 To whom it may concern: I am writing this to request a (one) copy of my marriage certificate. It was dated April 16th, 1967. The certificate was issued to Eileen Frances Hauver and Carson Bohlinger, and took place in Hopewell'Reformed Church, in Hopewell Junction, NY. This document is important to me and the original has. been. misplaced. . Enclosed is the form that 1 have filled out and the check for ten dollars. Thank you for your time. My address is: Eileen Bohlinger, 7024 Hildreth Court, Charlotte, N. C. 28226 (fYl &I~J(l) m ~ (J 6'rY\ rf\-. Gft,p /' -j ~/'7 ;. . ,"/ ':~"- .. ... ." ~d- ) Sincerely, Eileen F. Bohlinger . . ' -( I J C--~~/l " 8'$~1 My ~ ~ u...... ....Q'I a, am , ..~'* ~':' ~':~',"Ii e.. ~ oW. .....".~ :.~ \ :; ~ ~~ . 'I, U l t~r;"" ' 'I, Ii< w . "f$HH,''''.'.I' N"" \ \ GCX-) ~,v J 1 t~~1 ~"U~ ' ~~'f.. ~O~~ G .. I'" I 'llr... . f!.fl ! I e'" rFl~1 .!fJt il)1 .' .. Iii - r .Ill eJ: . t~q " ~ . . il,l ~ f 0' .. /Yl2'f' J't/4' "'~/"-'" "'OIA_ ..;> d I J 'Y1\I fJo;> c~.s t9k" , Application to Town/City Clerk for Coer of Marriage Record .., NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section 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 wel/ as date and place of birth of the bride and groom. Search and Certified Copy D Fee $10.00 per copy A Certified Transcript includes aI/ 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 settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) ~room E WIh:- Z- ~fride '7J7 WII-L2- Groom's Age Bride's Age or Date of or Date of --r / ~/ Birth Birth ( / ~ 0 Residence (State), / Residence (County) ~room A./I ~fride 6Glld ~ Date of Marriage If Bride Previously or Period Covered 2c /.Ir1 9 r9 Married, State Name -r-. by Search ( { T 6 Used at That Time Van Ie Place Where Place Where License Was 1/'1 /- Marriage Was ~ ~ Issued / vg ~//::; Performed T 1/- ..... .. ......... ...... ........... "'...... ........... . .. -t What is your relationship to person whose record is requested? If self, state "self.". ,~ L2L , t/;?}p( _~ (Stat;,}) / Ny ~ I In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Sig tu~~ of Applicant Date ffl Please print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) .- ., .... ..~ JUN-1-2007 11:12A FROM:TOWN CLERK ... (845)298-1478 P.2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section TO: 18774868560 Application to Town/City Clerk for COe.,\' of Marriage Record Search and D Certification Fee $1 0.00 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 I:7f 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. PLEASE PAINT OA TYPE Name ....-- (First) (Middle) ~room ~~ \ (~o.,rA_Vh i III Groom's Age ~ ~~~ateof LJ..e~ III 1 q bS- Residence (County) (State) ~room 'b ri0G (Y'\ e Date of Marriage or Period COvered b Search Place \NIlere - Ucense Was Wo.. p r I n C:.t ..e r Issued \J (Last) I rU\D(\E' lqq3 For what purpose is information required? 'To DBIAI ('J ARe P b ('.fI J'Y\ Pit t-t ,-, . 0 r; Q__ (' e +, h C'6.....+'€_ _ tc\Q Name of Bride Bride's Age or Date of Birth Residence .'7.... (County) :ride P%m ~ If Bride Previously Married, State Name Used at That Time N (). Plac~ Where l\.).J.Jf'-J oC; \1 E~ m L Marnage Was \J L c f) ,,\ ., . () 'L Performed QQ ,(J-J<...., I '\t ~- \U '0<....1. (First) (Middle) (Last) \)~6~c- rnor '-p t.0l' V\C( j~'0e. U; \ l Cf bb What is your relationship to person whose record is requested? If self, state "self.. S 12. ~ \:. . If attorney: Name and relationship of your client to persons whose marriage record is required. Date l :Tun.Q_ \ Please print name and address where record is to be sent. 2c.()P!GS !D', l?:.> 'CiS .1\\chA-p.d~~0(<_ \ L LU'\{\0X \ IIVC-._ B:.i n n{1Wy-toN \\.~L0 012. 'L Ij<1 D c~ p~ \(:) ~_ (PLEASE SEE REVERSE SIDE) --- - () tmlljrQ u2A LL r - Aftfl ; 'bl(\Q. '3R1'u\J tcl~ T vJO G-..ee.V'\ wC>~ plQ ~~ Sv,t02.. "2.ob . . It>J3~ \TX '77046 DOH-301 (3/93) .. June 1,2007 Town Clerk (Marriage Certificate) 20 Middlebush Road Wappinger Falls, New York 12590 Dear Sir or Madam: My wife and I require the replacement of our certificate of marriage, which cannot be found. Enclosed is the completed application and a photo copy of the original. The document is needed for a foreign visa, which we urgently need to process. Your immediate assistance in helping us complete this request is greatly appreciated. We are requesting three (3) copies of the certificate. We would like one of the copies mailed to the company assisting is with the visa process. Both addresses are included on the form. If you have any questions, please call my wife Debra, as I will be traveling outside the country. She can be reached at 1-607-772-0482 (home) or 1-607-222-0965 (cell). ,/2' f\ nf .~V l (L Richard P. Browne Jr. 'l'1~1a. )~~~ I vt)~ ~ Sandra Sullivan Notary Public State of New York No. ~SU6105658 Residing in Broome ~nty Commillion ExPi_FetltuIIty 11, 2OJ!i ~ 'II 01 Application to Town/City Clerk for Col!)' of Marriage Record r---/ Fee $10.00 ~ per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. -. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and Certification e $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 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. PLEASE PRINT OR TYPE Name (First) (Middle) of Groom Groom's Age or Date of Birth Residence of - Groom Date of Marriage or Period Covered by Search Place Where License Was Issued s (State) For what purpose is information required? 'id4.~ccd'S~ In what capacity are you acting? 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 Marriage W Performed (County) (First) (Middle) . ( ((~/k2- What is your relationship to person whose record is requested? . self, state "seIf.~ If attorney: Name and relationship of your client to persons whose marriage record is required. ..~ DOH-301 (3/93) 67 Please pint name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) -~,~ III NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for ColD' of Marriage Record 1::::;-: ... ..::<..}:'>T'.Y.'.,"'.p..,""S.>O'.'P}R':""S.......'c.' ".O><R.'O'}O....<e...:S'./R.'e.......'<<'C'.".ne... ,.,>..,.<.>,.,.".,.'o.':.....,"">"))}),::,.:",:".. . ........ . . ......... ... ... ... ......... . .. .... ... . . .... .... ....... .1 D. ...( ... . cR.. .. n.e}............... ........ .... "-', ...... '" .. ". . . .. . ...... .... ....-..-...-.-........-..,.-.. ..._'...... '....-.- .... .-....... ',' .:........ .... '." '". --. .... "." ,",',. -." -,'.' -..-.-.',.- ...., ','-'-.- -. ....-....................... . ......... ..... . .... . "'. .... ............ ..-.. '. ... .... .,....... '.... ..,. - ........ '-. -. . .-........ ..........'....... .--....... ........ ...... ,-... ........-.................... "'-'-'--'....-. -", ... ......, ..... ...-,._--- .....,. -,,', ....... ,...... ......... .................,....---....... ,. -- --..._-- - -..,.... ...... ......... ..,---. ........'................-.-.-.-,.,........-.. -.-'.................,. '''...-..,...".. ._--... '....., ..... . -..... ....--,,- ---..--.............'" .... ............-.. --...--.------...., --........_--. --. .......... Search and 0 Certificallon Fee $10.00 per copy A Cerllficallon, an abstract from the marnage 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 ~ 0 Certified Co y .. Fee $10.0 p per copy A Certified TranSCript Includes all of the items of Information occurnng on the original record of the marriage. A Cerllfled 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. PLEASE PRINT OR TYPE Name of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) (Last) I tU,OJOW J'~ /310 (State) 11'1 /$31 For what purp~ ~s ;;Ot~:J.~~eqUire~ to <<I ~--- f\!j----____ '0 what 'apa"~ a'e you a'5d!J?} Name (First) ~frlde fA '51t1!d. Bnde's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed What IS your relationship to person whose record IS requested? If self, state "self." s.e.11 - If attorney: Name and relationship of your client to persons whose marriage record is required. Address of Applicant M 40 ilf r I 5'froi; f( S1e ISor !()006 DOH-301 (3/93) 5: pc; /01 Please print name and address where record is to be sent. f/ta.;e 115e ft.ltc/osel rdurA f!)U/d~ (PLEASE SEE REVERSE SIDE) .... Dear Sir or Madam, I hereby allow the Town Clerk/Town of Wappinger to release a Certified Copy of my Marriage Record to me. The date of marriage was 12/24/1997 and our names are: Oksana V. Shmatkova (maiden name) and Daniel L. Jacobowitz Also enclosed is a Applicatkion for Copy of Marriage Record which contains additional information you might need about us. Thanks in advance for your help, and please call us if any additional information is necessary. Sincerely, t/.~ Oksana Jacobowitz State of New York County of New York Swom to and subscri~ befoMffMit:\ onthis';Odayof ~7 .2o~7 "l ~~/L KAfYA REKHTMAN NSt8IV PMbl/e, State of New York ND, 5005098 ~~Iifi@{j in New York County @@RBt@ filid in New York County ~ffi~i@1'\ ~res Nov. 30,2010 KATYA REKHTMAN Notary Public. State of New York No. 5005098 Qualified in New York County Certificate Filed in New York County Commission Expires Nov. 30,2010 .. "*"'" . ~tltl\\ca\\ot\ \~ ~~~\;-eRecO'~.. , 110 OEPI'<"",E"" Of \lg>.L1\1 tot CO 0 .......""'",Wii~#fii:J$ ~lo"':!::. ....... ..... 0 fee $'\0.00 ce..;tied COl'i pe< cO\l'i searc" and " cert"'<""on pe< cO\>y . \' 'udes a\\ ot \he itemS ot intorma\iOn . d I'< ceo"I'ed 1ra"""''I' ,oc . I'< ~on, ao abStract ""," "'" ",,,,,jag, edreco~ :;::;,. 01 occ,,,riOg on "'" original record 01 "'" ",ama<le. "" \leal'" oeparfl"""" "", ti es 1 \ ti- ",e seal 0 e . . at ",e "",e "'" liceOS" . i t ",<<1 be nee<Jed "",ere proo 0 me cOOtracU.,g p"",es,.;""" r":,;:::::: 01 .."" 01"'" """" aod I'< ce"",ed "~~ o",er detailed iOtor"'at\OO otl3'I be _ ....,.., as ...\1 as ate ao perenta<!" an rt _eteran'. """",\5, c<>tirt required such as', pasSPo s. groO"" d ee<!'ogs or ,"""""",0101 an es..te. I'< ceo"I'cauon ",<<1 be os<><las proo1 ",al a "'arria9" occtitte. pro< ' ~ ~ pLE/'SE p",,," 0" 1'!pE ...... (F""~ ..ame (f'rs~ ..llAipd\el,- ~~ i> S 01 A J L A. 01 -:J)A fl/trl... )KO"~ t'I .;."."... BOdO f!. t.-I pl GroO'" Bnde's I'<~ e GroO""s Me ... or oate 01 or oate 01 41' Bi"" Bi"" (state) "esi- "es","""" (COtiol'f\ . I 01 01 '7\... ~1,Io-SS IV Bride GOO"'" V TC-' " Bride p"",i()tiSIY oa\e ot Marriage ~ 00 /t'J 0 J 1 Married, state Name or p.,norl """ered .Jfi V' ' " 7 0 ...,. \lee<! at That 1\",e 'r>'/ sear'" p,ace W"efe IJ p,aceW"efe tAla >(<' NY lAarria~Vlas f/P ~er 1111" f'IIA ~~. 'f';;;';";" port><>"" is -","\\00 .....red . " sell, state ....... ;).l f /t;ce'" I ~ nA L- .::::--------- lMidd\e) IJS\) J [LtlWlS 5~ lCOun\Y) 1>vlth;sS ls\a\e) }J' \t a\\orne'1: Name and r~la\iOn~hlP ot '1' whose marriage record IS requIred, \n wha\ capacity are '1ou acting? _fi;rtI!2 'S".g~;; "~iAii' ",ay p\ease print name and ar :DAr1IGL. ~() () l.a rc1 c /1ic Pl..~ I'<Qdr"g; MueJi t. Ro ^ D J- a 1 r(J81 'f tJl J I~ fJ'/ /25cfD lPLEASE sEE RE\lERSE sir OOH-30'\ ls/93) -----------~ l.. NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record Search and D Fee $1 0.00 Search and D Fee $1 Certification Certified Copy 0.00 per copy per copy A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the Health Department, includes the names of occurring on the original record of the marriage. the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed information may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate. :::::~:::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::11..1:::111111.mi::::EIII:::III:::IIII:::ftil::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of D~ tAc..~ of t)\\-e e ('J A 8 \A.'f- \/'0 ~ Groom ~ Bride Groom's Age Bride's Age or Date of 3-;)..1-7/ or Date of 1- ) '0- (; . Birth Birth Residence (County) (State) Residence (County) (State) of v... \C.\.~<;;. S vJ of CJ "-"- \c.\r. t': s S v0 Groom Bride Date of Marriage If Bride Previously or Period Covered YVOU 3t> ~ Married, State Name by Search Used at That Time Place Where Place Where License Was 1"' C>....)v..) ~\ C$.l Marriage Was -'(( O~ wt\-~H\VU Issued W V\- '" '(J .; o/\J . Performed 0 v.) N .4? (Z..j For what purpose is information required? p(to~r c)~ T~p. What is your relationship to person whose record is requested? If self, state "self." 5-z\~ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date )- ;- 0-' Address of Appli nt ;}.Q:,\~~~ Ave, f\()l d- ~\J..~ y... \l~-(.~S.\<- vJ 'i ra 60 l Please print name and address where record is to be sent. t:S (2..u..c,e..... '\ ~\\P\ d- G, ~"o{l..('A. A v-e.. A~r:J.... ~o w "^- \. e.. ~ \ <- -JJ f d- (;,0 \ DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) Z/~ ----------~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and D Fee $1 0.00 Search and 0 Fee $1 0.00 Certification Certified Copy 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. ~ C' (/ i i/) PLEASE PINT OR TYPE Name (First) J ~room - _..:.'nm_.,..,-tr Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (01' C h 9/21 (County) ) U IcJ1r: J (State) t/ /V. " 6 5'/9 >L ~10! (First) (Middle) Lr(: (Last) J (), Jre h Name of r1 Bride 1"'/0;'7 /'?C{ Bride's Age or Date of Birth Residence (Coun ) ~fride Ov C f /,t' S If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed Ie 6'[/ (State) /4/ (/ /VIA I-IOJ -J;fO/0VI//C C' i (,'/1:" What is your relationship to person whose record is requested? If self, state "self." ~~. Ii;: For what puq:jose is informatio. n req~ired? d J 0 fa rz f Iq trcR' In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. p--v) Address of Applicant DOH-301 (3/93) Date Please print na ~~ c~~~~------ a'(' ------ o ..- (PLEASE SEE REVERSE SIDE) .. -~'- J' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe}' of Marriage Record Search and 0-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. PLEASE PRINT OR TYPE Name"".....) (First) ..-_---,-{Middle) ~room ttl~ ~ -1CJSC-P?l Groom's Age or Date of //_ '7/;. _ < I Birth ~?\ u:: u.: Residence (County) ~room -::D i1Tej'.:k::.:s' 5' Date of Marriage or Period Covered Ll-eJ2G: - 0 7 by Search Place Where . I .____ ucense Was \'J'" I\(\j tJ (.i!JL t 0 V /oJ.. Issued "IIJf-Il Co' ~st) 1l1-Af\I&uqt (State) lV (3. iAJ }0~'- i-IA L L (Middle) L6C 1 J;A (Last) [FA N{JL~A bI Name "ffirst) ~fride 1.:'1 f..(f..1,l( Bride's Age ( or Date of 4 _ i I - ;: 7 Birth t.-t LV Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (State) AlE. t.J Y;1t i:. ~ ~cou~ty) J)v \(....j1i?S '7 For what purpose IS information required? -'''I N\N'\I {,~f{ ; O{J In what capacity are you acting? What IS your relationship to person whose record is requested? If self, state .self." If attorney: Name and relationship of your client to persons whose marriage record is required. srgnatl.ll'e ,pf A . ; ." tJ-.d~.:-:..r J ! 1:~;iQ1'J~J1i1;h,ilJ.j" . AddreSS/Jf. Applicant I L ' c: ; Y LL- ~ ~.I-l 3H f,Sf/J-1 './ i.J ;.:-- I 1.1 LL f\1Sl (d. :"))-, t',Sl1.......t ( DOH-301 (3/93) Date . / I I"') / 1- (Ju - )007 Please print name and address where record IS to be sent. ~~B~ ~ APR 2 6 2001 J) (11, ,,1 IN / B Y: _~_G~w.._~~-- (PLEASE SEE REVERSE SIDE) - NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and D Fee $1 0.00 Search and 0 Fee $1 0.00 Certification Certified Copy per copy per copy A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the Health Department, includes the names of occurring on the original record of the marriage. the contracting parties, their residence at the time the license was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed information may be required such as: passports, veteran's benefits, court A Certification may be used as proof that a marnage occurred. proceedings, or settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) ~room C: h r i s tc he r J: \) aSSo Groom's Age o~ Date of CA - 1-. \ -l U Birth ~\ I Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Last) (First) Ch~. ,she I-Y-"7G t (Middle) ~~(.LYiG (Last) (VI\).. (County) ~ 0 rYldse t tD -1-04- ., O-VV1l\ ub 'W' (State) NJ (State) rJJ tN ~Yj(?r5. For what purpose is information required? !.~ c h a t"-j ( vJ11 M a Jl1~ What is your relationship to person whose record is requested? If self, state "self.. S ~ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date L/ -30 -0 Please print name and address where record is to be sent. hid jV\- pe(SOh DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) , -~ ~ ,. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coey of Marriage Record Search and D Fee $1 0.00 Search and ~ 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. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of of ((\-1. Ir-+-hG II"' ""JJ;t 0 I" 1 Groom Bride ~ , ~ I Groom's Age Bride's Age or Date of or Date of 9 ~ - / 9 I 8 Birth - .";;l - Birth Residence (County) (State) Residence (County) (State) of of D uk ~es C Y'tr Groom Bride 'S o'-\. f\)ew fa { t: Date of Marriage If Bride Previously or Period Covered Married, State Name by Search Used at That Time Place Where Place Where ~- mar'"! \ C h 1'\ Ucense Was Marriage Was J Lt r( Issued Performed Wet lip Pc< {ts AI,V I 2S '"' <1 For what purpose IS information required? What is your relationship to person whose record is requested? If self, state .self. " S e ;.{2. In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant , Date 0- tv,~ 9J~ 'f - :;;. Lf - 07 Addr~ of Applicant Please print name and address where record IS to be sent. ~ ~I Ct dd [ Y1 cf WqPf' FCt I IS fIJ .y i ZS-r 0 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) ,4 .~ Application to Town/City Clerk for Co of Marria e Record :::::::::I~::::::::::::::i:::::i:i:::i:::::::::i:i:i:::i:::!:::::::::::::::::::::::::i::::::i::::::::}:::::::::;:::i;::::t:::::::::::::::::::::::::::i:::::i:::::::i:e.:::II:::il:11161:::III,=III:i::IIIIII:::llll:i:i:i:::::::::::::::::::::i:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i:i:::::::::i:::::::::::::::::::::::::::::::::::::::::1:::1:1:::1 ,/ TOWN CLERK NEW YORK STA~k/JfdE),EALTH Vital Records Section 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 r!1/"Fee $10.00 W 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. :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::1:11:11_:::11111Bg::::mlll::::.I::::I:III:::~..::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) of J\ Groom ,~ Groom's Age or Date of Birth Residence of " Groom Dt..ATq-h SS Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) W; v\..{'~ (Last) i t.. \ ., d ~4' (County) (State) (VI 01 ""3 3 Tt.<f{..S ~ C~ (first) . (Middle) . (Last) L,lA11}'Vt UJ )vi MI' <-- ~ 1" (>r{'i 1P 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 Marriage Was Performed ~ (State) ~ It l:f't.- 4 ') . cKA1J.h... 'L fi. '^ ^ PI I.,) tV \A. '"\vLtt 7" G ~^-J11 What is your relationship to person whose record is requested? If self, state "self." For what purpose is information required? /f(\-~~r 0 ~ In what capacity are you acting? 5~LA~ If attorney: Name and relationship of your client to persons whose marriage record is required. ~lt.~ '--~~~ OfA~ } tl 3 Lf \ ti)'L U I liV DOH-301 (3/93) Date J{ ;;..D 0"1 Please print name and address where record is to be sent. I ~f~'1ftL. ~ \-4.~ fl'-TO yJ 34 \V~ ~ W~~ ~G'ULS ~S Iv'1/~54i) (PLEASE SEE REVERSE SIDE) .. Application to Town/City Clerk for Co of Marria e Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and D Fee $1 Search and D Fee $1 0.00 Certification 0.00 Certified Copy 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. PLEASE PRINT OR TYPE Name (First) (Middle) of Groom .. C- Groom's - ge or Date of Birth Residence (County) ~room OV+C-hl~0 Date of Marriage or Period Covered by Search 00 I Place Where Ucense was-J ~ (l Issued () '-l\ 0 -\- Wt::t Name (Middle) of Bride Bride's Age or Date of Birth Residence (County) ~fride f 0 i (\ 4 jIV\,.. If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (Last) &~ VI (Last) YcYJ (State) 1Jl{ (State) v For what purpose is information required? 0: \.)O~e What is your relationship to person whose record is requested? If self, state "self." sc../f In what capacity are you acting? S~Jf. If attorney: Name and relationship of your client to persons whose marriage record is required. Date Address of Applicapt F2d $"3 ,..5c.., 6D \.Jctff: "eSe, {Ails AJC{ I 2 ~9 D Please pr" t name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) , -~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and EJ 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. Search and Certified Copy Fee $10.00 per copy 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 settlement of an estate. 6 (q//s PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) (Last) (First) (Middle) (State) 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 Marriage Was Performed (County) "/ 3-/'f' (County) (State) \)~ 'fls.5 fJ. . ~- For what purpose is information required? /05+ 0' r ( j; /)'-/0 ,I What is your relationship to person whose record is requested? If self, state "self." In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signa r~~~ ;Plij' ~ {h Address of Applic!nt ;0 {{Jc/or S 51c1C?fs hv(O IVrtt 07 Please print name nd address where record is to be sent. ! J.j? 6 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) d APR~ ~o~ BY: ..L........ ........ ----------'-- I I I r' I -', h I ~ .,',<'C \~ U~,d' ... NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coey of Marriage Record ::i:::il!:ii:i::ii~:!iiiil!i:::i:i::i:ii::::::il:lil:l:ii~::i::i::i::::::i:i:::iii:i::il:!::i::::i::i::i!i:i:i:i:i:::i::~l:~i:~i:::!:::!:::j:!::~!:::!::::::lllli:IB:!:!I:IIIII:::lllllllij:jllllll:jilllli::!:!i!i!:::!i!i!:::!:!iiii::ii:!ii::::::i::::::j:::::!:::::i:::::::1:::i:::::ji::::::::::!i:::::i::::::::::::!:i:::i:i:::::i:::i::i!::~::i::i~::::~::::!:: Search and D Fee $1 Search and ~$10.00 Certification 0.00 Certified Copy per copy 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 occurnng 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:::i:::::i:i:ii:::::::i::::::i:::::::::::i::i::!i::::::::::i:::::ii:i:::::::::::ii:::::::::::::::::::::::::::::::::::::::I_I:i:_II'-'III::::IIII::::llli:illll:::llli:::::::i::i:i::::::::i:i:::ii:::i::::::::i::::::::::::i::i:::::i::::::::::::ii::::::i::i:::::::i:::::::::::ii:::::i:::i:::i::::::::::~:::::~:::::::: (Last) Name (First) (Middle) (Last) of Bride ,1\ ? Bride's Age ~~~ate of /0 d 3 J 8 ) (State) Residence (County) (State) of Bride If Bride Previously Married, State Name Used at That Time Place Where S ~oJ.15 NY ~:~~~~~:as We s\- PC') \ (\.\-) rvY PLEASE PRINT OR TYPE Name (First) of I. . Groom i/-.___e..- V \ ,') Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) ,=) } ~ rt (County) For what purpose is information required? T\J '2 Q ~ ("J ( \ ~ \ rol. C!..vp~ ~o (l hi (" ~ ~ ~ S ~ C. n--J:: c.... In what capacity are you acting? ::b C- ~ d&- What is your relationship to person whose record is requested? If self, state "self.. 'S~ \ ..Q. If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant (/}1'~ ) Address of Applicant I d tJ ()..( \'-1..- \ Lo....N\JL ~(Y\ Q.,\~ NY 10<5 I d- DOH-301 (3/93) Date Please print name and address where record is to be sent. Id D~\'-1\ L~~ C-&..r~ NY 16 Sf 0 / (PLEASE SEE REVERSE SIDE) iF'~~~ JJ APR ^ ~ ~ 2007 J) BY: _..(!f!f!IL__...._.. ,. ---------~ -~ " Application to Town/City Clerk for COe)' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and D Fee $1 Search and ~ Certification 0.00 Certified Copy Fee $1 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::::::::::i:::::i::::::::::::i:::i:i:::i:i::::::::ii:::::::::i::i:::::::::ii::i:i:::i::i:::il!I..:::BllwB.::::IIII::::III::::IIII:::651::::::::::i::::i::i:::::::::::::::::::i:::i:i:::i:::~:::::::i:~:::~::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::i:i:::iii::::::::::: PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom 'I v -\ t. 'he ~ Date of Marriage or Period Covered (y by Search D Place Where Ucense Was Issued (Middle) (Last) '"Ro e,S ~c Name (First) (Middle) of \,.- Bride "etfi e Bride's Age or Date of Birth Residence of Bride Dv-\-'l:\e~ If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Z. Performed \C7() C hvf C k (Last) C. I ' b 1b Ib1) (County) ohY\ (State) (State) '( "--\ _l.JI For what purpose is information required? Lo &+ on',:! I A.... \ What is your relationship to person whose record is requested? If self, state "self." S-e t f In what capacity are you acting? G f C) (1 ""'" If attorney: Name and relationship of your client to persons whose marriage record is required. Date '3 eJ7 Please print name and address where record is to be sent. ,+: We- DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) .- -~~, Application to Town/City Clerk for Co of Marria e Record Search and L,\PoI d3l:t Search and Certification ~ ee $10.00 Certified Copy {"'3"\:;I' ercopy 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. .. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section A Certification may be used as proof that a marriage occurred. 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. t:rrrrmttmmmrmmr:::::::::ttt:r:::tt:r:t::::t::tmrr::r:t:r:::~b.:bE:D'E":':}~~~"(::::~'Ii"':)re"')5'R":"..:.M....:....t~.~.l.:)i~i;.M...::.....f:..t;.E..:.:}:t:r::rmmr::rrrmm~::tmrrrrrrrrrrmtt::::~::r:::tttt::::~:t ;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:::;:;:;:::;:;:;:::;:;:;:::::::::::;:::::;:::::::::::::;::::::::::::::::::::::::::::::::::::::::::::::::::::E::.:.:.::..:.:.:::.:::::.::.::..:::.......:::~wm'-1~h.jl~~....:...:::::.:::::e::.:::.:.:.:::..::.::::m~I!M:::""..::....:J~~~~~~:::FHL:.:.::::::::::::::::::::::::::::::::::::::::::::;:;:;:;:;:;:;:;:;:;:;:;::;::;:;:;:::::::::::::::::;:;:::::;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;::::::::::: PLEASE PRINT OR TYPE Name of Groom Groom's Age ~~ate otJ - \ 5, (;;J , Residence ~unty) of I \ 't' V 11 Groom .' ., vi'" Date of Marnage or Period Covered ^) - I L ( - C ') ~S~~ ~ I . Place Where . t ( ~ License Was I; ~ \ ' ' !\ Issued Vv i In what capacity are you acting? / ,;0 A , /" \.:.../ L.---,'~ ------. Addr of AppliO&[l.L.. f {' \ " / ( it-'~ e.>-t,' -l v ;Li (l L (i(CJA 'I ~lt\ ~) (~( ( ( S'V l( ( {'2 C)t; () DOH-301 (3/93) Name (First) (Middle) . ~fride J 1[7 ( ~tg:~: ~~l: - I" / ,-/ )Il '1,' / 1 Birth v VJ V j . t ' if::ence a G -r;tyA-~ \ r ( , I If Bride Previously Married, State Name Used at That Time Place Where ~ Marriage Was , ~.(; Performed ' 'fy What is your relations . to ~on whose record is requested? If self, state "self." (' r If attorney: Name and relationship of your client to persons whose marriage record is required. . b7 Please print ame and address where record is to be sent. IrXrrll ,V1 \H~ Ct:-Z L( ~o:trv ?1Vlr~('vtlcl(\" (,40{.. . CCtl V P '~M~ll'S V\C I ?_\ G() (PLEASE SEE REVERSE SIDE) ;;.. .. --~ Application to Town/City Clerk for Co of Marria e Record ~"'1,i~ee $10.00 ~ per copy A Certified Transcript includes all of the items of information occurring on the original record of the marriage. .. 1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section O 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. Search and Certification 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 ceedings, or settlement of an estate. A Certification may be used as proof that PLEASE PRINT OR TYPE Name (First) of ~ Groorr::U..CMl' N. <:. ,<- Groom's Age or Date of Birth Residence of ""'r'\ Groom IAJ Ie L.. Date of Marriage or Period Covered . I ./. c. by Search /, LIt',' / Place Where ' License Was Issued 0 I~ ,).D (Middle) (Last) ~Ar/~ Chl'~rc) /0/0 ~I b7 (County) (State) Ai.'/, 2vo~ (First) (Middle) J41Arl ~NNC,,- (Last) NCt-/e; ,. Name of Bride Bride's Age or Date of Birth Residence (County) of ' I Bride '-:Pc... f-c~ If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed 2//3/ t;:, ~ (State) jJLf . / 5-1(:/ feN Is ~- ~v I." /eLCPl rJ , In whaq; you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. s~a- Date S/;S/U7.. .m.mmmmm..mm.m Address of Applicant Please print name and address where record is to be sent. J q 00rIV fCkrp s LJflrP'~r< r f"' h II> IU"Y. / '2 5)" 0 DOH-301 (3/93) , ,;J (PLEASE SEE REVERSE SIDE) / / \ ') .~'- :, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe}' of Marriage Record Search and D Fee $1 Search and 5a' Fee $1 0.00 Certification 0.00 Certified Copy 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. PLEASE PRINT OR TYPE Name (First) ~room -, ,cu.' i d Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where Ucense Was Issued (Middle) (Last) ~nSL (First) (Middle) (Last) F\ 8 -dPl~loCi (County) ~ \-5-0..<:;:5 (State) N'v Name of Bride Bride's Age ~~~ateof q -de; -, S Residence (County) of ~ Bride --Yu..~ <;;'.5 If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (State) l>-S-Q3 ~. As ~c\--lQ"", 'o;'4Sj C4:.k--+ ~ W . ~~S For what purpose is information required? LDS+ ~"'\0~ REGEW In what capacity are you acting? What is your relationship to person whose record is requested? If self, state "self." <:: 0 \..(2. l' ~. attorney: Name a relationship of your client to persons whose marriage record is required. 1~ \S ~.~. Date 3- I.)--O( Please print name and address where record is to be sent. '~0 'Ko-r--Q. \ S Sc. ~G \. 'S.-\ - - . -qD ~\~-e'(~~\~o \d-Sl-D Schou l s::\- (PLEASE SEE REVERSE SIDE) tb-{(-lZ/,~::if; [) 0/'1 - -------- -------- ~- "'" .r NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COE!)' of Marriage Record :i:~:~:~~i~i:::::j::::::::~i~~~i~i:!:i::~i~:~i::::::::::::::::~~::~i~:~:~:j!~::::i~~~~:~~::~:~~:~:~~~:::::~i~:~i:~~::::~::::~~:i:~:~:!:::!:j:!:i:!:!::::~i~~.li~!1I~i:l:iIIB:g~~~III~III:!::flllll~i~lfll:!:!~~:i~:~i~::i:i~i:i::~i~i::~i~i~::::~:~~i~i~~~i:~~~:~:::~:~~~~~~~:~~~~~:::::!j::!:::::::i:::::::::!:::::::i:i::::::::::::::::~:::~::::i~~:i:!:::!::j!:!:i Search and D Fee $1 Search and [XJ Fee $1 Certification 0.00 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 bene.fits, court A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate. ::::::~:~::::::jjj:::j::j::~:~::::~:j::j:::::~~~:~~~::::~j::::::::::~~~~~~:~~::::::::~::::~~~:~~:::::::::::::::::::::::::::::::::::::::::::::::::::I:II.I~:~_II..:~::IIII~~~~III::::II:III:::~.I:~~~~:::::::::::::::::::::~~~~::::::::~~~~:~:~~~~~~~~~~::~~:~~~~:~~::::::jj:::::::::::::j::::j::::::j::::j:::::::::::j::j:::j::::::::~::::j:::::::::: PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) ~ 2 ~ Groom h-lt.(/ tcry'lv1t~'~'1v7< ('C( (~(\ j'/ Bride 011 "h 1\)c:\ '~1 WIt; Groom's Age // Bride's Age or Date of c:; or Date of ...,..-") Birth / / - / 9 - &.7 7 Birth (:::; -- ,7 () -"? Residence (County) (State) Residence (County) ~room -5 ~ '7 c: i1 ~ (I("i KD VI," ~fride ,>6)7 ~,;i, ec{( .R Date of Marriage If Bride Previously or Period Covered 17 /. ..~ ,:/' Married, State Name by Search- ,/ t' ,..- ~./' / Used at That Time Place Where Place Where ~~~~ewas lj:lj;// /Iv C;7rj t<--1 tj ~:~~~~::as.)C' he/)/ <:::~l l\/r-"/i/f{VY (Last) (\:-1 {(7 y" / (State) ~'/i t/~yjJ,jVcl/' (~f'::cF~iJ."F\"~:fi.,.J For what purpose IS information required? /. 1 )-;;- j"v"\ V /-. I (' (-/ tv' .::> e::: ! What is your relationship to person whose record IS requested? If self, state "self." ~,<,' I ~ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Si!:!nature of ~pp~icant ~.. _ / ;<~:>/'::,{/ . (.t.~.:>,_' Address of Applicant.c:-" ,- ,~ \ 7 5 AI t' ('\ Q (.:? Date ; ~ / - c/ 17 KT,> I , "r"' <..(,1 I-. ~ (7 Please print name and address where record IS to be sent. , r ? ' 1, - - (,./ L 'I if I /v ty (- I 1/ / / /; .. \( fJ I DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) ( -~ . -I /' NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record Search and D Fee $1 Search and D Fee $1 0.00 Certification 0.00 Certified Copy 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. PLEASE PRINT OR TYPE Name (First) ~Mfdle) of 7)1i flIIFL ~D b~ rl Groom Groom's Age .::JIr or Date of ~ Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (State) Name (First) ~fride /I LJ f 1+ Bride's Age ~ or Date of 0 Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where ~:~~~~::as !fDDlt, r Aile. (Middle) (Last) fiE litiS (Last) t.7JW*~ i) S (County) l)urd, '-5S AI DEe. 0'1, /9E'f NafJfJ'I1ft ~~ NY S5 (County) J)uft~.s s (State) N For what purpose is information required? ~ I'e/J/t;ce or/9/IJAL , , What is your relationship to per n whose record is requested? If self, state "self." .s.{ In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signa', ofA(! Date May 2 f, 2. ~()1 · Please print name and address where record is to be sent. -:t>111J IG'L €DINAR 1)5 ~() ()~rl.e lid. 1.4 r~ t f),{ (t: 12-54tJ Address of Applica7t /') -3D fJe li'- "OPt D t..a 1raYI'fVI//( J1l,/ 125t1D DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) .--------- "'-. NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coe.Y of Marriage Record :::li:::i::::::::i:I:I:ii:i:i:i:ii:lilii:iil:I:I:I:I::::::~'~:::i::::::::::::i:::i:ii:::i:i::::I:::::I:::I:::::::::::i::::ii:i:i:I:::I:::I:::::I:I:I:::::I:IIIIII::1I:::IIIIII:I:lmlllll:I::IIBil::i.i::::i:i:ii:i:::::::::I:I:::::::::::I:I:I:::::::::::::::I:::I:I:::::i:i::ii:::::::I::::::::::::::::::::::::iiili::::::::::::::::1:::::::::I::i':~::ii'~:::::1 Search and D Fee $1 Search and D Fee $1 Certification 0.00 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. :::::::iii::i:i::::::::::::::::::::::::::::::::::::::::::::::i:iiii:::iii:iii:::::::::::i:::!!:!!:!!:::::::::::::::::::::::::::::::::::::::::::::::I:~I.I!!:I_IIIII:::IIII::::III:::IIII:::III::!::!:::::::!:::::::::::::::::::'::::::::::::::::::::::!::::!:!::::::!::::::::::::::::::::::::::::::::!!::::::!:!:!!::::!!::::~:::::::::::::::::::!: PLEASE PRINT OR TYPE Name (First) ~room /KEVIN E~ I"'/+-IC(/()-er Groom's Age ~~~ate of ~ ( d-- ~ l \ t1 S- j- Residence (County) ~room DUJ~ Date of Marriage or Period Covered by Search Place Where License Was lfJ' 1,fJ,.) J Issued I-f I r (I ,lv' 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 Marriage Was LJ Performed (First) Vefve J..-e~ r"] II y. \ 11 s 1) (Middle) (Last) (Middle) (Last) ,...., (State) (County) D w-J\.t.o AJ . Vel v~e- I{<J nq-l , V t- J C -e,#\ -e4-~ (State) , f~dJ N, ~u f!J \ ( For what purpose is information required? t);J.X So '? ~Yf What is your relationship to person whose record is requested? If self, state 'self." S FLF In what capacity are you acting? s-r: if If attorney: Name and relationship of your client to persons whose marriage record is required. . Date Please print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) fl~ /i 09tJ~ -~ '- . Application to Town/City Clerk for COe}' of Marriage Record NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and 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. ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::~:~::::~~~:::::::::::~::::::::::~::::::::::I..i:::I.lgBI:]iIRI::::Ba:::I:BII:::...:::::::.:,:,:::,:::::lm;,rlrlmmt~t::~::::::::::::::::::::~:::~:::::::::::::::::::::::::::::::::: PLEASE PRINT OR TYPE Name (First) of ,~, Groom '"..{' Groom's Age or Date of ('" Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) 12- (Last) . -I r-- (le~ crt? J L. (State) T', Name (First) (Middle) ~fride "y \ S-h. - JCl - Bride's Age ' o~ Date of Q. 1'1 c::::'J 1 U. Birth () ~ - ./ I Residence (County) ~fride Ld-r ~I r-s; If Bride Previously Married, State Name ..., Used at That Time , '\J Place Where Marriage Was Performed (Last) Let2 '[{)ilL (State) N\.-' fCcLJ s What is your relationship to person whose record is requested? If self, state "self." For what purpose is information required? ~l)1t'( I \j7fJ tr In what capacity are you acting? ()'e t-f, C)(Jf 1<-1 )1{) a 11 nuln1aLt-- ~S'e If If attorney: Name and relationship of your client to persons whose marriage record is required. ~ol PO~u. hg Pfpje rJ,,{ /1-lJJo DOH-301 (3/93) Date Please print ame a d address where, record is to be sent. C '(' t'5-h..j -, Ib~ I-e B ~ a YlC 2. J efPeY50j"7 jec.! VCUt:', 11 L?- (PLEASE SEE REVERSE SIDE) ~ "-~'''-' . ~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town Clerk for Coe}' ~f Marriage Record .......................................... .................... .::...:::.rn'Mel:,..II':,:I,IIII!I:!III'III:~I_lilgil::.!:i: ..............,............................ ..................... .......................................... .................... ........................................... ..................... .......................................... .................... ........................................... ..................... .. :.;.;.;:::;::::::.:.:.;:;:::::;::::.::::;:;:;:::::;::.:.;:;:::;:::::;:;:::;:;:::::::::::::;:::;:::::;:::::;:::::::::;:::;:::::::; ... .;.:-..;.:.:.;.;.;.;.;.;.:-:-:......... Search and D Fee $10.00 Search and ~ Certification Certified Copy Fee $10.00 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::.::':R:ti~IRE:,!QllpERli:!:FIRM::i:iND:::il:Elnm::FEi:::;:.:..:::::::':<<:;:;;:"':. .........-:.;.;.;..:...:.:,:..;.;.;:.......:...:::;.::.:,..::,.;,;:::,:.:..,:,:::;.;.;:.:.,' ..... .... ... ...,:..;.;:.:...:...:;..:..;:.... .........:....;..:::::.:.;.' .. :::::.;:.:;:::::;::::::-:.;.,:;.;.;.::;.;.;.;.;.:.;.;.;.:-:-:-:-:.;.;.:-:.;.:-;.:-:-:-:-:.;.:-:.:-:.;.;.;.;.:-;.;.;.;.;.;.;.:-:-:.;.;.;.:-:-:-:.;.:-:.;.;.;.;.;.;.;........ .;.:.;.;.;.:.:.;.....;.;.;.;.:.:.;...;.;.;.:.:.;.:.:.;,..:.:.;.;.;.;.:.:.:.:.;.;.;.;.;.;.;,..:.;.;.;.... . . . . . . . . . . . . . . . . . . . . . . . . .. ...... . ........ . . . . FEES: Make money order or check payable to New York State Department of Health. Please do not send cash or stamps. There is no fee for a record to be used for eligibility determination for social welfare or veteran's benefits. PLEASE PRINT OR TYPE Name (First) of, ,... I .'\ Groom D( L.- II n Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered l i"7 I ,.c.;- by Search Iv \)./ Place Where License Was Issued (Last) lA.-iJhu (d I\J ~ Name (First) of ~, Bride IjJt(i' I' ) \ t Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (Middle) (Last) /j l(~((lre {/-O CtJ J.YI III (State) (County) I LA..' CI'-.P-55 (State) iJ N )11 For what purpose i.S infO. rmation required? ( \ {uSrt ( t ( t? I \Q ~\.,'6-- ' What is your relationship to person whose record is requested? If self, state "self.".s.1 \ f In what capacity are you acting? Sl\~' If attorney: Name and relationship of your client to persons whose marriage record is required. Date I . d'J.U;' 0 l Please print name and address where record is to be sent. I t--\ \-<l/~ddl VVt) P? jll~'/?() DOH-301 (3/93) I)S(7b (,,-;; ~rth\...( (PLEASE SEE REVERSE SIDE) RECEnlE FEB ; VS-34M TOW", r.1 r=qr. v,.._,c....,~~ ' .. ; --~ . NEWYORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Col!}' of Marriage Record Search and D Fee $1 0.00 Search and ~ee$10.00 Certification Certified Copy 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. :::::::::::::::::::::::::j:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.._:::IIIBmlll::::1111::::111::::8:111:::1_1:::::::::::::::::::::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i::::::::::::::::::::::if::::::::::: PLEASE PRINT OR TYPE Name (First) of ., Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Middle) (Last) '-:)0 JJSD,J liNt L\) W , 01;0-0/S0 (County) DlrfCf. -35 / 7/3/ V.r((It6i:' ~Pffiv~6.K.5 (State) ;vy' Name (First) of /1 Bride ~ K'r"S7l.-c.- Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where V A; 5.5 A.e Marriage Was ).::::> t> ty L" I Performed 0 r , (Middle) (Last) Fu-; E Y 9-/3-5(;, (County) (State) NQ. o A 0 B:4P. ~ 1-/1.1 Rc }v.r< For what purpose is information required? ;7/V/I/Ut... M EI'\J7 In what capacity are you acting? 5~~LP 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. / )...If" /259{) DOH-301 (3/93) Date Please print name and address where record is to be sent. (PLEASE SEE REVERSE SIDE) ~ . ... Application to Town/City Clerk for COe>' of Marriage Record r--i 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. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and Certification 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 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 settlement of an estate. PLEASE PRINT OR TYPE Name (First) of Groom 1'-1/' I \ Groom's Age or Date of Birth Residence of ....;' Groom / ;~,...../ Date of Marriage or Period Covered by Search Place Where Ucense Was Issued Ct/ /J ') 0 (Middle) ?~/./E -" '" Name of Bride Bride's Age or Date of Birth / / Residence of () Bride <:~--'VI/ If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed (First) (Middle) .9 '5- s-" (County) (State) ~... ~~.:L (County) (State) I 8..2. ---. J #/~ .Fo~ ~at "p~~p~~.is i~f~~~~tion required? What is your relationship to person whose record is requested? ~. A" If self, state "self." 0' a-"L:J. ,/4-"/" J2:JJE ~ /)0(/.1" t. 1/, In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of Applicant " " Date >18310 NIV\Ol (PLEASE SEE REVERSE SIDE) iOOl - 83-' 03AJ3838 / ;O":.:;~ .)'Li 11/0- f . Jix.UJ-tl { /.IV\ /(!,.iL. -- l/. .' ... \... DOH-301 (3/93) '" i . t. '[l/fflH/,fllln"nlllllll Z'HEREBY;MAKEAN' ' ~T08EJ;FFEc'n,VE U ... A. JJ ANl"NEE lB.o THEFOLLOWINO Ii ~ a; o Z . NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Co of Marria e Record i!i!:::!i':i:::::!:::::::i:::::::::i:::::::::i:::!::::ii:::::!:::::,,:::::::,::::::;;:;::j:i:::::;::::::::m;:i;:;;:::::::::::::::::::::::::i;:;ii::::::::i:::,,:i::;:::::;:::::;:;:I:::II::il:IIII:I:::IIIIII::::IIIII:!:1III:::::::::::::::::::::::::::::!:::!:::::::::::::!:!:::!::::::j:::::ii::':::::i!:!i:::i:::::i!:!i!':::i:i!:::::::::::::':::::::::::::::::::1:::::::::::1:::::1 Search and JAN 2 6 2007 D Search and @ l&J Certification Fee $10.00 Certified Copy Fee $10.00 o E per copy per copy A Certification, I~ a't{~ac9lrom~ 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 groom. 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 settlement of an estate. """""""".,.,.,.",.""",.""",.;".,.",.,,,,,,,.,,,,,,,,,,,,,,,,,,,.,,,,,.,,,,,,,,,,,,,,,,,,,,,,"""""""""""""""""""IIIIII"'11II9I1Em&("lllrjf'III"".'II1II1"'81I"""""""""""";"""""""".""""""""",."""""""",.,.,.,.""""",.,.""""",.",.,."",.,.,.",.,.,""""".", .......................................................................... .. ... . '. . .. " .. . ......... . .. .......................................................................... ......................................................................... ." -.. '. ",.. . ... . .... . ........................................................................... .......................................................................... .. ... ........... ... . .... .. .. ........... .... ... ... ............................................................................. ......................................................................... .. .. ...... ............ .. ...... .... ........................................................................... .......................................................................... .. . ...... ........ ...... .. ..... .......................................................................... ......................................................................... .... .. ... ................ ...... .... ..............................................................-............ .......................................................................... .. .... .. ..... . .. ....... . .. . ... . ...... ................................................................................ ......................................................................... ... ......... ..... ... .. .. ...... ........................................................................... ::::::::::::::::;:;:::::::::::::::::::::::::;:;:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::;:::::::;;:::::::::::::::::::::::.:::::::.:.:.:::.:.:.:.:.:::;;.:::...::;.;.:.;.;:;:;:;::.:::::::::.:::::.:.:...:::.;;::;::.:.:.:.....:.:.::;..:::........::::...::::::::....:::..:::..:...:...:..::::...:::...:..::...:.......::::::..:;:...:...........:..:.:....:;:...:::::;::.:::::.....:.:::.:....:::::::;:::::::;:::::;:::::::::::::::::::;:;:::::::::::::::::::::::::::::::::::::::;:::::::::::::::::::::::::::::::;:::::::::::::::::::::;:::::;:::;: PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of JOH~ -- \./0 L-K V\A~ }J -:rR of U N ~'A- (\;\ AA l~ f}) pp Groom J Bride Groom's Age ) I Bride's Age ( )1 or Date of 0 C1 1 q l q 7 5 or Date of 0 9 I 5 q 7 3 Birth Birth Residence (County) (State) Residence (County) (State) of lJ V TC.. *:5 s N V of t) 7C HE35 ;\Jy Groom Bride 0 Date of Marriage ] ) If Bride Previously or Period Covered 0 5 .3 i d- UO 3 Married, State Name by Search Used at That Time Place Where Ap ((~f< Place Where CoL-{J b ;J f( /,vc; /!1l?!l/[) 0) 5T CrfL!(cp6. License Was /}J p i IJ ,~ FA-U,S Marriage Was lfJJWP5 fWJ AJj tV J Issued Performed i For what purpose is information required? What IS your relationship to person whose record is requested? f-t1)oPf7 Oru If self, state "self." S EL-F In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Signature of APPliC~~ 11,1 II ofti.l,?0"--, Date i/~ w/o ( 'IA 1/1 vfr.,e' ( '7 , I Address of Applicant Please print name and address where record is to be sent. S 3 n 1 r:j( !< Olti) /) Jl//U C176/t! ;Vi I --' J-1 () ff /)Vi e J 533 - J' DOH 301 (3/93) (PLEASE SEE REVERSE SIDE) .. . , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for Coer of Marriage Record Search and D Fee $1 Search and rsJ Certification 0.00 Certified Copy Fee $1 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. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name of \ of Groom ~J 0 Bride Groom's Age Bride's Age or Date of or Date of Birth Birth Residence (State) Residence ~ ~ Groom '7 Bride 0 00/'1 € Date of Marriage If Bride Previously or Period Covered Married, State Name ._ by Search - 8 Used at That Time Place Where Plac~ Where "2 O/V C P / oS, 0 /' /1 L. C/i t/ e {' II License Was M Marriage Was / (First) (Middle) (Last) S-/5'6 (County) (State) For what purpose is information required? Rrf1/aC(. /0.51 hreosc {nof J(ln' i.J1.r.~ ~('X Ie rj,€rk fi6o,,',,) In what capacity are you acting? ,5/:>O.16f1.__.________ _________. What is your relationship to person whose record is requested? If self, state "self." 5 f! [}.- If attorney: Name and relationship of your client to persons whose marriage record is required. //J!::- Date / j;tJ /IJ 7 Address of A plicant / /:3 J'J; Ie /.s/;;rJd Pr. En cf,'co f-/ /Y7 /3 7~ 0 Please print name and address where record is to be sent. II- ie/I'" }o:;,... S. Ales Ie ~,r>,::n orl 1/:1 j'.k /' ~ ;J I ~ h J ,lA-- Enj'-col-/ /V Y /37(, 0 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) / tl r>7 a 6,' " c!<.- n. I .oS / ke- e cI yelP?,) t-vof /1 G/(J.:t.51 ,< 7/ W~J jul.';l Mil II //8/~C' w Iv.; ( j'ce-?.!( rnc.;.-,r{ "'"Jt <..; Cl.J O}O. /7 78 ~ Jt: 11:; c1cl ~ ,~ ~ ~dcll.)./ ,"1 ~ f;; ," j rJ?q ."~ 7 /]t;;.~~ j?!c4t.Jc rc /SJ C/e. ~l / 'c c7/JC.C ~ nt L , ~ \)/\. ~W~ \O'}'1J fJRIVERt E ID:822 949349 008:07-05-56 WESTERM,ANN,J,S 113 SKYE ISlAND DR ENDICOTT NY 13760 SEX: F EYES: HA HT: 5-07 CLASS: 0 E R: B ISSUED 07~ EXPIRES 07-05-12 ;..-1__-/ J.;;.:t::= 56040450 '1f<:t"/,{ ;Pr.... )( >1nll:r S. M.s.Ii?rrz-r~PI ~ 1-1 xl Q~ 1/3 Slye /;/r,..,cI' 0,,_ i-..., j/c v ff /Y y /.1 I (, 0 11'111111111111111111111111111111I11 11111 E~DOfl$EMEt<fI'S: Z I HEREBY MAKE AN ANATOMICAL GlFT. (NONE:) ~ TO BE EFFEC11Ve; UPON MY DEATH, OF: c A. 0 NIt NEEDED ORlW/S 011 PARTS R~.:-es ~ B. 0 ll1E FOlJ.OW1NG BODY PARTls): Ii! z it C. 0 llMlTATIONlSl: i SIGNo\TUAE: o . . . Q WITlESS: I...~..p-.._..-"..q-'I i ::ss: Page 1 of 1 Sandy Kosakowski From: Chris Masterson Sent: Tuesday, July 18, 2006 8:56 AM To: Sandy Kosakowski Subject: FW: marriage license Chris Masterson, Town Clerk Town of Wappinger 20 Middlebush Road Wappingers Falls, NY 12590 845-297 -5771 Office 845-298-1478 Fax -----Original Message----- From: Jennifer Westermann [mailto:skyejenn@stny.rr.com] Sent: Monday, July 17, 2006 10:37 PM To: cmasterson@townofwappinger.us Subject: marriage license To the Village Clerk: Is there a way I can obtain a copy of a marriage license without being there in person? It seems as though we are only in the area during non-business hours. The marriage was that of John H. Westermann, Jr. and Jennifer G. Strong on August 27,1978, Zion Episcopal Church, Wappingers Falls. Thank you for any help you can give me. Jennifer S. Westermann 6/~1/~~ _ - A I~:to rtt-~ ~ t cI~ ~ ~ ~~/ ~&at !,/1,c7 712012006 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe)' of Marriage Record Search and D Fee $1 Search and .~ Fee $1 Certification 0.00 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 mamage occurred. proceedings, or settlement of an estate. .:.:.:.;.;.:.:.:.:.;.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.;.;.;.:.;.:.:.;.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.;.;.:.:.:.:.RIIii.IS........:...:.:.:.......:.:.....:.:.....;.I........:.:..;.......SU..:.....:.:...;.:...:9.......:1...:.:.:.................&.........:.:e..........:.....:.S........:......:.....:.;..;.....:.JI....:....O.......:.:.:.S........:e.......:U.....:....11.............;.&........1........&........:.:.:.:.:.;.;.;.;.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.: ................................................................................................................................................... ..... ,",' . .... . . ..... ......" ..... ," ..... . .' ',' ..................................................................................................................................................... .......................................................................... .. ... ........... ... . .... .. .. ........... . ......... ............................................................................. PLEASE PRINT OR TYPE Name (First) of Groom Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was Issued (Last) dYlGl Name (Middle) of Bride I \ Bride's Age or Date of Birth Residence (County) (State) of Bride Dv L If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Cot d Sp'f ~ '()(\ Performed J (County) (State) Dr o..x) \\JL; ql2.2\ D t,o \rJ C\.pp \v\ .ev~ For what ~.r ossee is information required? . -tQSS ~(t What is your relationship to person whose record is requested? If self, state "self." ~ \.f In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. Date Address 0 I cdO'7 Please S;~;~ ~~ess rRC::~~C\nl 12SS0 DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to Town/City Clerk for COe>' of Marriage Record Search and D Fee $1 0.00 Search and [i] Fee $1 0.00 Certification Certified Copy 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. ::::::::(:::\'\:((:::j:::::::::::':':::=:::::::::::::;::=::::::::::::::::=::=~:~::::;;::::::::::::::::;:::::::::ft:::::l::::::!:i!:!.I:III:::_Rgg~I::illll:::111::::I:III:::III:::::::!:::':::::::::::::::::::::::::::::!:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::!:::::!::::::::::::::~ PLEASE PRINT OR TYPE Name (First) of G Groom reli Of" Groom's Age J or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where ~~~~e Was W d.VP IV)Cj e (" S Fo. \\ S r N 1 (Middle) M lchltd (Last) Power o {g - 11- I~ (County) South Bl?stcn (State) MI't- oq - J. ~ - 0 (J) (Fi rst) (Middle) f otH GI GL (Last) .J, D v (x. 0. V) r~y Name of Bride C cill,l e(n Bride's Age or Date of Birth Residence of Bride If Bride Previously Married, State Name Used at That Time Place Where Marriage Was Performed 01- ~\-llo (County) Sou m ~D~i-on J (State) MA. FI'shb \\) NY For what purpose IS information required? Name Chl1Vl~ 0 n Yasspf\r\- In what capacity are you acting? What is your relationship to person whose record is requested? If self, state "self." ~ elf If attorney: Name and relationship of your client to person~ whose marriage record is required. Signature of Applicant ;/ cZv It (i t1 '\ -Ii '(:(j Address of Applicant ~jL!JLc DOK-UleskY" STreet- So u th B()(;,fo(}) ;VIA #j- OJ / ).1- DOH-301 (3/93) Date 1- g ~. Of Please print name and address where record is to be sent. Cothle-en ?O\N€V ".)1.1>(( Oor( hC"~te( Sr(eet I Ui'\\ \- 'It=t-. 5c um Bas. tvn I ,/I!\A DJ.l ~ -=r (PLEASE SEE REVERSE SIDE) All{ 'l . ,'. !)flf '(1/ /1 t... / I J or January 4,2007 Chris Masterson Town Clerk 20 Middlebush Road Wappingers Falls, NY 12590 845-298-1478 RECEIVE JAN 1 0 iC TOWN CLERI-< To Whom It May Concern: I am writing request a certified copy of my marriage license. I am requesting this to document that my name has changed to Cathleen Power for my U.S. passport. I was married in New York on September 23,2006. The groom's name is Gregory Michael Power. My name was Cathleen Patricia Durcan. Please send me 1 copy. I have enclosed the $10.00 fee for this servIce. Sincerely, ("171'~) -I~. Cathleen Power 366 Dorchester Street #7 South Boston, MA 02127 l evtL6tt Uo.% CoU~ ~~ ~ LAURA G. GARDNER ja.u..na...' NOTARY PUBUC COItIIONWEAL TH of MASSACHUlETTI (f) . UY~~ JUNE 12.2009 ~cl~~roct ~cr(.Q I -- If1 '~ ~ ~ ~ 'P Application to Town/City Clerk for Co of Marria e ReCQf:r/) ,:',;::,::::,'!::::::;::::):::;:!;::;;"",::;;!:'!:::::::':;::;;;;:!:'::::':',:,::1,'::!::;::::!:;!,:",:;'.,:",:,:,"'i.!;:.l:.@_:':IB_}_:,j.I~:I:":'::'::\:::"::';'!"';::'::;:':':':::::":,;;,:,;",:,, NEW YORK STATE DEPARTMENT OF HEALTH VItal Records Section 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 parnes, 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 / ~ 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. REC PLEASE PRINT OR TYPE Name (First) ~room C. Ii R v. /1 e- Groom's Age or Date of Birth Residence of Groom Date of Marriage or Period Covered by Search Place Where License Was J)CL~p: J "\.Cj c'.A/- Issued / (Middle) 1-1 d-/2-~/'I3 (Last) IV. / I,' Vt775 (County) (State) [) V -t- ~ ), e, '5 :5 IV tJsTJtj j9ft] (First) Name of Bnde Bride's Age or Date of Birth Residence of Bride If Bride Previously Married. State Name Used at That Time Place Where Marriage Was 1-,' 5 hIe, / / Performed / 16LEr (Last) F/ofl-~ce 2.. G; / I :5 /C/I/~C (County) f) v-l- cJJ e.-5 S (Slale) /1/Y For what purpose is information required? ----P-Y- ~-f--l2- D y -f-s / r t::- +. / e- ,,7/ e4 In what capacity are you acting? _~e 6r,cle- DOH-301 (3/93) What IS your relationship to person whose record is requested? If self, state "self." / C Se-. rr If attorney: Name and relationship of your client to persons whose marriage record is required. / 07 Pi it n me and _'ess '"""'" '_d ~ k> be sent (PLEASE SEE REVERSE SIDE) ILL (/&~~' ~ ' (}(j)J//( 6z~ Application to Town/City Clerk for COe}' of Marriage Record - NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section :':::jij:jjjii!ii!::!::::i!:jj:i:!!!:i!::i::i!:::j:i:j!ii:!j:i!i:!:::::!:!:::::::!:i!!:i::i:::!j:!!j:j!!!j:::::::!:::!:::::::::::!:::!i:ii:::j!jij::ii:i:j:jllll!::lIi::jl:gla:lii:III"III:::j~IBilijiIRl:::!:!:!:::!:!:i!::::!::j:!:j::::i:ji::i:::!::i:::::::::::i!:jii:::!i!ii:::!:::::::::!:!:!:::::!:::!:::!:!:!!::::j!j:i!j:iii::::::;:::::::::::::'::i!iij::i Search and D Fee $1 0.00 Search and ~Fee $10.00 Certification Certified Copy 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. :::::::ii::::::!!:!::::::::::i:i::iiiii!ii!i::::::::::::i:i!j!!::::::::::i::!:!::ii::::i::::i:i:ii::iii::::::!!!!:!:!:!:::i::::::::::::::::::::::i:I&:8.:::III.II11.ll~III::::III:::IIII:!:I.li::ii::i::::::i::i:::i:i::::i:::!i!!:::::iii::::::::::::::i:!:::::!::i::::::::::!::::::!::::::::::::!i!:iii!i:i:i::::i::::i::i:::::::::::::::i'iii::: PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) of 'S N of \L;/~(1 \ ~ CV-O \ \ (~YPIM \ Groom ~\ '^ '" C 'r 0 'SoW E- \ I Bride \h s...u c. Groom's Age Bride's Age I or Date of .2.- I 3- I t <1 s ~ or Date of /0 Is I ~ S.s Birth Birth Residence (County) (State) Residence (County) (State) of 0 ~ <-\)~ '1 of 0 u ,<...\~ ~ s' S !oJ'( Groom U S <; N Bride Date of Marriage /0 I If Bride Previously or Period Covered C I I 2.L')C> ( Married, State Name N. ~ V E v"'\ by Search Used at That Time r Place Where Place Where t\> .. \"",; ~ "-\l ,~ M:: 1(. \L.\.---. C ( t Vh;t License Was lu i-\y\) I rv l?, If it <; ftl, II <- Marriage Was oJ u. p P I I~S(!)-~ (~ II ~ Issued Performed For what purpose is information required? What is your relationship to person whose record IS requested? If self, state "self. " l...c:l<;. "' L\. <"\$-"<" ~ S 6 L F In what capacity are you acting? If attorney: Name and relationship of your client to persons \4-0 S\"G. ~ whose marriage record is required. Signature of Applicant ~ Date ~(;~.~~ J AJJ ~ .-r>( I 2.-1 '2...l.J I 2. ~\:) Go Address of Applicant Please print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) .