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2012
WEW YORK STATE DFPAHTMF_NT OF HEALTH 1 vcg Records section Application to TotimlCity Clerk for Copy of Marriage Record TYPE 4F ~~GQR#3 t~~~tE~ {Ent~lf` ~i~rnber o! dies) Search and Fee 510.00 t per co Certified Transcri Search and Fee $10.00 C rtifi d C ^ py p e e opy per copy A Certified Trarrsaipt is an atutract tram the marriage record rued under the A Certified Copy includes afi d the ftems d infamtation ooaurirrg on the original seal dthe town/city clerk n includes the names d the carrtrad'mg parties, their record d the marriage. residence at the time the ficenae was issued, date and place d nrerriage as weN as date and place d birth d the bide and groom. A Certified Copy may be needed where prod d parentage and certain other detatied ~~ ~ ~ ~~ sudr ~' ~°~' veterm's bermfds , A Certified Tr m be used as arrsaipt ay proof that a nrsriage ooaxred. cowl prooeedmgs, or settlement d an estate. Sri e Name (as recorded on marriage license): Date of Birth: g ~~' ~93~ ri.r ararr i..r eHraiw. If Previously Monied, State Name Used at that Time: Residence (at time of marriage): ~. ra.r aw. &i~i rrttS~cuse _. Name (as recorded on marriage license): G v1"a~s~r Date of Birth: '~ ~a~~ ~~,~ ~ 9~i /~/ F..r ~rrr.. wr ewa,r.» If Previously Married, State Name Used at that Time: Residence (at time of marriage): Frr.r tarda. ~ aw. << Marriage lnforrt~sEot~ :` >::. Place Where Marriage License Was Issued: Place Where Marriage Was Perfom~ed: Marriage Certificate No.: Local Registration No.: ~j~~~N~af f,,rLlS ~~JiC/~G~S Aa..~r A~ Taw ~r Tew M Purpose for which record is rec~ired: ~ Date of Marriage or Period ~~~~j ~n~r ~~~~r~ ~: s~iC o°(.II~ ~~~ In what capacity are you acting?: ~t ~ !~ ~ ~ Pw~ wtrose re~rd is required't ~~~~~ (If salt, state'SELP.) ~ ~~ Sre6lrr ~Isi.aiigP.la1 ~./dd//7'ri) If attorney, give name and relationship of your client to person whose record is required: 'gnature Applicant ate: - ~ ~~~ 'call's hone Num r. ~ls-- a q~ ~ ~~~~ Name~rp pl~ ,~ ~`~~ ~ ~ ~~ PI print name and address where record is to be sell: ~ mss l~) ~~)~~~ ~~~ Add ss of plicartt ~~ 1) ~~ ~ QS~~ ~ ~ ~ i7 ~ r~~ ,~ h z ~ p o~J (w/r ~~~~N~~s ~,~~~~ , ~~ ~ aSgo L~~~~N~~.S ~LCs ~~ )~ ~~b Cifj' 3fsfe ZIP t~ty sta. ZIP uvn,~u~ rolnl rope ~ or z _~ AIEW YOFaC STATE DEPARTMENT OF HEALTH Application to Totlm~Cidy Cierk for Copy of Mania a Record , vdal Reoads sediarr ~ g 4 ,~_ TYPE t~F ~~Ct3Rn ~~~a1 .,, Search and Fee 510.00 Certified Transcript per ~ A Certified Transaipt is an abstract tram the marriage record issued under the seal d the towMdty dark. It ardudes the names d the aorgraaUng parties, their reaidenoe at the tune the tioense was issued, date and place d nraniage as weY as date and place d birth d the bride and groom. A Certified Trensaipt may be used as proof tlrat a manage ooowred. Name (as recorded on n e-~-{? I If PreviousN Married, State Name Used at that Search and Fee S10.00 ~~~ ~Py Pm' SPY A Certified Copy incMrdes aB d the items d infannation occurring on the original record d the marriage. A Certified Capy may be needed where proof d parentage and certain other fist anew wr 81~1r BrldeJt~rmt~otaee Name (as recorded on marriage license): Date of Birth: ry.e ~'~ f' ,,;~,. ~os e p r-, ~ f~e-~1,5 G (1 erw~.r~s...a `'ll ~~b~lJ Residence (at time of marriage): __ _. Marriage<tnforrnat[orn . Place Where Marriage Lir~rrse Was Issued: (.JPpPi~~..c ~ S A v-~cti~sS re.~.. iwn « Purpose for which record is reined: ~02 C,nfh~ r G ~vtcl-, ~ ~~~"~~ In what capacity are you acting?: Wit ~ Y~ {If self, state (Z¢ ~Cf 1 CC) reationsrrip to person 'SEEP.) Residence (at time of marriage): Marriage Certificate No.: Local Registration No.: A-~•q R~ Date of Marriage or Period Covered by Search: Mni~dNra / n arraMiawr ~~~ii~l s~ ~ ~ If attorney, give name and relationship of your client to person whose record is required: s~2 y/~z ~~r 7 ~~.~yA~ Address of Applicant: ~~ // ~~~~~r~~o~ ti ~osi~-- ~..'°'''°` I a~w.•~•~r ~•iadn,,,- 'lease print name and address where record is to be sent: -_ ~ orz Place Where Manage Was Performed: ~l~r~a5~z L~~~nce~ 1~~~ ,~~~~ a ~ ___ __ __ ~..~NEW YORK STATE.: ~'' 4 ~ : ;_ ~ I)RIVTR _LICENSE ~. ~~ ID: 40$ 438 065 `'CLASS DM 3~ ; k ~ •• t ,.~. REAGAN ,i.+ , PETER,J , ~ '~' ~ ~ `' 28 HOME ST ~' ~' a - < <~t " HAWTHORNE NY 10532 ~ DOB:04-16-!98 ' ~ SEX: M EYES: GR HT: 6.09 E: _ NONE ~_: H: NONE ~~~~ ISSUED: 03-03-11 LhN113ES 04.1&19 IUAZMpUK00 `~J~4J'~ ~y~ ` - V "J ~~ t~'VII YORK STATE DEPARTMENT OF h~ALTH Ydal Records Secfian _--~ Application to Tottm/City Clerk for Copy of Marriage Record Search and Fee St o.oo Certified Transcript ^ p~ spy A Certified Transaipt is an abstract from the martiage record rued rsrder the sect d the torm/dty deck. ft inductee the names d the aontracbrg parties, their residence at the dme the fioense was issued, date and place d manage as wetl as date and place d girth d the bride aid groan. A Certfied Trensaipt may be used as prat tlrat a manage acaxred. ~~ ~~ f State Name Used Residertoe (at time of marriage): L-os ,~us~e~PS ~,~ ~r arr. Marriage Certificate No.: Local Registration No.: N1""'"r Meww~- ~1l~~GGct'.~G~ ~ ~r~ 5~-a~t s~s In what capacity are you acting?: What a your relationship to person whose record (Iiselt, state'SELP.) S~l~ 5~~~ If attorney, give name and relationship of your client to person whose record is retired: - ~~ ~~ ~~~ Name of Appli ~~ Address d Apphcart>r ~l _ • v v ~_ rowN S~ ZIP ~Y DOH301(8~11) Pia 1 of 2 Search and ® Fee $10.00 Certified Copy pet spy reonM d ~ srdrldes aA d the items d information ocauring an the original A Certified Copy may be needed where prod d parentage and certain atlrer detelled rtrfarmaban may be required such ss: passports, veteran's benefits , court prooeerirrgs, a settlement d an estate. Date of Maniage or Period covered ~ seardt: ~~ ~ 3 o?oa~ N••~adi ~~ p...as„P.s.~r ~•iadi,~ S`4~.s~'- ~3 S'- 9 9S-o to be sent: I,c~ Di`-~ 3(~l~ L 5~~U3~ ~ NEW YORK STATE DEPARTMENT OF Ffi=ACTH Yrtal Recede Sectim Application to TownlCity Clerk for Copy of Marriage Record TYPE t~ R~Ct3R~ ~~Ftf~ tEntsll~N~mberaf ire Search and Fee 16to.o0 Certified Transcri t er co Search and Fee $io.oo C ~ p p py ertified Copy per copy A Certiified Transtxipt is an abstraa from the manriage record issued under the A Certified Copy indudes afi d the items d irdtxmatian ocairring on the original seal d the townlaty clerk. R tirdudes the names d the oorraacting parties, their record d fie marriage. residence at the time the license tree issued, date and place d rnariage as wee as date and place d birth of the bride and groom. A Certified Copy may be nestled where od d pr parentage and certain other A Ce-tified Transai pt may be used as prod fhat a marriage otxurred. ~~ erlornra6an ~ ~ rettuired such as: passports, Meteran's benefds , oast prooeedmgs, ar settlement d an estate. i3rfde1E3roamlSpoutae Name (as recorcied on marriage license): Date of Birth: ~ ~ ~ ; C - 1~-+a.,ri..er.~ay -- a >~ ~, ~ o ~ ~ ~ awrw.. ~ a a ~ If Previously Married, State Name Used at that Time: Resider>ce (at time of ma 'age): t<.er arwerr. tart v.~1c S ~ arr. BrltietGro4mI5'~otts9 __ Name (as retarded on marriage license): Date of Birth: (a ~a+et tile. a w.eiy~l ~ awe. ~r ~ arr-ire,. if Previously Married, State Name Used at that Time: Residerxe (at time of ma ): ri.r wadr i.er srr :. Marris~ !n#e~ttstt .:: _ Place Where Marriage License W a s Issued Place Where Marriage Was Performed: Marti Certificate No.: ~ Local R istretion No.: e9 1 ` r - to..1\~ Are..N ~ F ~ ~ Twee ~ ~ Teewr M P 0 Purpose for which record s required: Date of Martiage or Period a55 ~ ~ ~~ C~~ ~ Covered by Search: ilnisA.w w - ~ a s~i~ In what c~aciry are you acting?: Whet is yow relationship to parson whose record is required'r X11 dye ~ 8oree for S e ~~~t~ N•~~innl If attorney, give name and relationship of your client to person whose record is required: 'gnature d Appli nt ate: A ~ s hone Number. ~ ~~~, 5 as i~ Name of Applicant: Please print name and address where record is to be sent: ~e9.~~~;e ~o\\;e~ Address d Applicant ~S~ locyr~ y~ew'~t'. City 9tete ZIP Cdy 8rr ZIP Dt7M.701 pytl) Pepe 1 of Z ~''~~ ~.RI~ STATE NEW YORK STATE DEPARTMENT OF HEALTH V~ Section Application to Town/City Clerk for Conv of Marriage Record search and ~ Fee s~o.oo I ~ ~ Fee sto.oo 1On per ~ P~ ~Py A t;,ertification, an abstract from the marriage record issued A Certified Transcript includes ap of the items of information under the seal of the Health Department. inchides the r>amag 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 Firth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed irtforntation may be requited SUCtI as: passports. vebsreTl'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) I ~ ~ (Last) Name (First) (Middle) (Last) I a~ t? 11 t Groom a ~ ~ Bride I l i orrDate of ~ ~~ ? /9 ~ ~ ~ ~ ~j or Date o~ ~6 "'- / fCJ ~' ~} ~~ /7 p~ Birth ( ` Birth pesidence (County) (State) Residence (County) (State) Cxoom ~S of Brims Q -~ a p pd ~~ /~ r q / ~ ~ / ~ R Bride P Metried, State Name t/ S dt / Used at That Tmne ear P Tnn~ ~F G(/ ~ ~' was Sf./~~ s C~icuc~ ~~ ,~ lasued ~ For wharf purpose is infomration required? Whert is your relatiorretap to person whose record is requested? ~Q f ~ If self. slats 'sedf.• ~' ,~- n what capacity are you acting? ff at~n ~~~ ~ whose Nerve end relatior>sfiip of your client to persons lags record is required. S' of Applicant ~~~ Da1e . A rasa of Applicant Please print name and address where ©to tle sett. ~~cv ~ ~y ~ ~ _ ~~~c~~2~ ~~~ ~~-~~ v~ ~ ~ 1 DOH-90t (8/t~c3) (PLEASE SEE REVERSE SIDE) Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marria a Record vital Records section py 9 search and ~ Fee afo.oo certification p~ spy A Certification. sn abstract from the marriage record issued under the sal of the Health Department, inckrdes the names of the contracting parties. their residence at the time the license was issued es weH ~ dab and place of birth of the bride and 9r~• A Certification may be used as proof that a marriage occurred. PLEASE PRINT OR TYPE Name (First) (Middle) ~, ~~ ul C3room's Age or Date of (l~1 11 n . 1 s. ". moon, 1)t ~~5~ Date of Marriage or Period Covered ~ . by Search Pbce Where 1~~~r~~ search and ~ Fee sfo.oo cernfied copy ~ ~, A Certified Transcript includes all of the items at information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed irdvrrnation may be required such as: passports. veteran's benefits. court proceedings, a settlement of an estate. (First) 5fi~~51B Reeiderxe (County) (State) Bride ~ ~ _~ Martied. State Name Ussd at That Tgne Place Where ~ S P ~~G h ~eer~ s~ ~ ~ ~ is you rebliormhip to person whose record is requesteo? If salt. atab'sett.' 4~ In what capacity are you acting? of {~(,~ r 2(oQ3 ff attorney: Name and relatiorrstrip of your client ro persons whose marriage record is required. ~•~• ~~ name and address where record ie b be sent. DOH-301 (~~), (PLEASE 3EE REVERSE SIDE) s1 Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marcia a Record vital Records Section py g Search and ~ Fee $10.00 Certification p~ ~y A Certification, an abstract from the marriage record issued under the seal of the Health Deparhnent, 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 lxide and 9~• A Certification may be used as proof that a marriage oxurred. Search and ^ Fee $10.00 Certified Copy per copy A Certified Transcript includes aU of the items of information oxurring on the original record of the marriage. A Certified Trerrscript may be needed where proof of percentage and certain other detailed arformation may be required such ss: passports, veteran's benefits. court proceed"u~gs, or settlement of err estate. '~'' PLEASE PRINT OR TYPE Name _ _ (Prat) (Middle) (Last) ..., ~~~ ~ ~ ~ ~ ~ ~ ~~ Name (First) (Middle) (Last) Bride ~P~ E~~ Groom V !- ` Groom's Age G / Bride's Age / Q (/ Residence (County) (State] (County) (State) Residence ~ ~-s t ~ i`~ ~ ( Wi f~ f~ TG ~~ lr s S B / n, ide Date of Marriage r ff Bride Previously or Period Covered /~ ~a g / ~ ~ Married. State Name Soh 6 ` Used at That Time '"w ~~~~~~~R~ ~ r-,5~~ ~~L ~- ~ y For what purpose is Information required? R o0 F D ~~ ~ ~} {Q 12 ~ /-~` G ~-. What is your relationship to person whose record is requested? Itself. amts '8atf.• S~ L ~ In what capacity are you acting? ff altomey: Name and retationstrip of yore client b persons S ~ L ~, wriose marriage record ie required. Signature ppkcant ~ ~ Date ~ oil ~©~ Address of Applicant ~ ~ / ~~ P~~~~ ~( Please print name and address where record is to be sent. ^ ~ ~ s ~~o ,~, ~ r~-n r~ ~- ~ ~ ~ ~a `F 8~ DOH-301 (3/Si3) (PLEASE SEE REVERSE SIDE) r ' Application to Town/City Clerk V~fal Records 13ection EPARTMENT OF HEALTH for Copy of Marriage Record searcn and ~ Fee $t o.oo certification ~ spy A Certification. an abstract from the marriage record issued under the seal of the Health Depertrnent, includes the names of the contracting parties. their residence at the time the license was issued as well es date and pl~e of birth of the bride and groom. A Certification maybe used as proof that a marriage oxurred. PRINT OR TYPE Search end ^ Fee $10.00 certified copy . per spy A Certified Transcript includes aA 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 requirred such ss: passports, veteran's benefits. court proceed'mgs, ar settlement of an estate. Name (Frstj (Middle) (Last) Name (First (Middle) (Last) of of Groom c., r- P~ Bride s Q~ f Groom's ge Bride's Age or Date of ~ ~ ~ a ~/ ~ ~ Birth 1 B / c residenc e (County) (State) Reeiderice (County) (S ta te) C3re~m ~~~ . ~ n r`~ P .C t --, 1~-~t Bride ~ r~~ RC~ Q..~ /l / ~ ~~ /_"C or Period Covered ~ Place Where License Was ~~ Issued ~a Married, 81a1e Name Used at That Time Marriage Was t'~,. , , For what purpose is information required? What is your reletiorrsh~ to person whose record is requested? If self, state 'self.' ~-ec ~~ ~cA 1 ~ ~ ~o S'el n what capacity are you acting? ~~ n attorney: Name and relationship of your client to persons whose marriage record is required. D1f,Ap~r1!?'%/ t / Dale f Aooiicsnt Please arint name 37t 5 Nor-N,. Va.kbst~ ~ f~ ~ 2 5" `f ~/ a(c~o S}Q ~ ~~ 31(voZ sent. ~H-g01 (~~). (PLEASE SEE REVERSE SIDE) 1 NEW YORK STATE DEPARTMENT OF HEALTH vital Records sedicn Application to TotimlCity Clerk for Copy of Marriage Record TYPE t3F 1~~C'fl ~~I~~~ (Enter.~~l~tmber of ties) Search and Fee ~t o.oo Certfied Transcri er t ~ Search and Fee $t o.00 C C ^ p p ~ ertified opy per copy A Certified Trarsaipt is an abstract from the marriage record rued older the A Certified Copy indudes aA d the hens d irrrfarmation scarring an the arigkrd seal d the townlaty clerk. It includes the vanes d the cartrac~ing parties, their record d fie marriage. re.~idertce at the time the ficenae was issued, date and place d marriage as weN as date and place d birth d ttre bide and groom. A Certified Capy may be needed where proof d parentage and certain other detailed udamratian may be regrared such as: paseparfs, veteran's benefits , A Certified Tr ansaipt may be used as prod that a manage ooarred court prooeetings, ar settlement d an estate, Brtdel(3t1/SpDUSe :;.: >, Name (as recorded on manage license): Date of Birth: (aey.ara.. 0/ arm ~~,~ d~ ~ ~ h ~ ~ ~ - yo , ,~. - ~ ~ 1 ~~. If Previously Married, State Name Used at that Time: Residers at time of marri ~~ ~25 s Fisf arcs. lnr ante &ide~lartaN>tit~5'J7okt68 Name (as recorded on marriage license): Date of Birth: N+aw~~.elw.ri~ !f Previously Monied, State Name Used at that Time: - Residence (at-time of marriage}: ~ v ~- t- arr. :: Marriage hrfortnatit3~ . , .; ,: ; .._ _ Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: W~rP ~ i n g eY- ~~-~~~e~s ~ap~i r,~ers ~t/S~ ufG~iLs s Aa...- A~•~r Tewi er Tway er Purpose for which record is required: Date of Marriage or Period ~f~s(/ ra /~ Ls ~- Covered by Search: alnird ew a n~ ~ 1, / p G ~ r..r ~J / In what capacity are you acting?: What La your relationsfrip to person whose retard is required9 ~,~~~~ (If self, state "SELF'.) aeaeh~ If attorney, give name and relationship of your client to person whose record is required: 'gnature d Applicant Date: s hone Number. Name of Applicant: Please print name and address where record is to be sent: ,C3r~~ ~w -/~~- ,~vr~ Address d Applicant ~ ` <~' ST ' / D<~ (~r~ T~~ ers p=~,lls , ,/~ Cdy Slate DP City Std ZIP uunwi ~nI repo ~ m t Where to Apply for Record of Marriage 1. License issued in New York State (Outside of New York City) Year of Marriage * 1881 to present (610.00 psr copy) * 1881. to present (530.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certfication Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.go~/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 ._ Yonkers: City Clerk 40 S Broadway Rm 107 .Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtydeMiwny~8ov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1888 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (8111) Pape 2 of 2 j __ _T,, Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH • ~;~,, for Copy of Marriage Record search and ~~ $~o.oo Certification par spy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes tine names of the contracting parties, their residence at the tans the license was issued as well as date and place of girth of the bride and groom. A Certification may be used ~. proof that amarriage oxun-ed. Search and Certified Copy ~ Fee $10.00 Par SPY A Certified Transcript includes all of the items of information occurring on ~e original record of the marriage. A Certified Transcript may be needed where proof of pan3ntage and certain other detailed information may be required such as: p~sporfs, veteran's benefits, curt proc~edin~, or se[tiernent of an estate. PLEASE PRINT OR TYPE Name (Frs~ ((Middle) ('1 (Last) Name (Fist) (Middle) (Last) ~ ~;q~ p Groom ~S ~ \ Ati~ \.'~.I~J~ Bride ~'~~ G. e~ or Date of n- s /3~S ~ or Date of ~ ~ lZ ~ l~G, 3 Birth ! Birth Residence (County) (3mte) Residence (County) (State) °~ Groom ~ ,~-~s `( ~ ~~~s N ~ Date of Marriage or Period Covered 3`~'il~ ( M Bride Previously Married, State Name Search Used at That Time PLicenseWW~ •• ee v ~ ~`- /~-~v ~ `~ ~ " ~` S ~.r~^5~ Marriage Was Qo,~ ~ - 70 "`" "~ Issued Perbnned For what purpose is information required? ~o~ l~Q~ g What is your retatiorwfiip to person whose record is requested? If self, state •aelr.• ,e ,~ ~ s b ~ In what capacity are you ac(tin~g? ff attorney: Name and relationship of your client to persons ~-o ~ ~1'~'C' whose marriage record is required. Q~ ~~v ~~ ~~ m,, ~,~- N ~ ~ 2 bob ~,~- name and address G°~~~~~d[~~ DoH-aoi (sus) ... (PLEASE SEE REVERSE SIDE) OF W AppINGER TOW N TOWN CLERK Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Certification ~ Fee $10.00 ~ y ^ Fee $10.00 f~ SPY f~ SPY A Certification, an abstract from the marriage record issued under the seal of the Health Department; ~incbides the names of the contracting parties, their residence at the Erne the license was issued as well as date and place of birth of the bride and g~• A Certification may be used as. proof that a marriage oxun~ed. ~' °'' ~' PLEASE PRINT OR TYPE A Certified Transcript includes aN of ti~ items of information oxurring 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 proceed'mgs, or setgement of ~ estate. Name (Prat} (Middle) (Last) Name (First) (Middle) (Last) of Groom ~ ~~ sS~•^O of .!i ~ Bride I ~ ~nar~n °L ~ z; Groom's Age ~0 ~ °~ y Bride's Age ~ °~ q ~ 3 - ~- o 5 - B, - unty) (Sta te ) Residence (Co Residence (County (State) 1 A ) ~~ ~ ` ( ~cJ ~''`~ S S /lf ~ Groom ~ / ~ S . grids Date of Marriage ff Bride Previously or Period Covered Q~ ~~ Z~~ 0 Married, State Name , _ Search CC~~ Used at That Time se is inbrmation required? For what purpo Whet is your relatiorreh~ to person whose record is requested? /l ff self. stele "self.' ~' (~ G-r'c e ,..s ~ In what capac acting? ff attorney: Name and retatiormt>ip of your client tb persons ~ ~ ~ ~ whose n>~riage record is required. Signature of Applicant Date y~~~ -/z Address of Appli t Phase print name and address where record is to be sent LIO T -~ ~xrf,.,.~ Ck Qo~S~- /UY- l26a3 DOH-soy (s/i~o) (PLEASE SEE REVERSE SIDE) ~ y ~~~ ~~ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH ~itel Records section for Copy of Marriage Record search acrd ~ Fee slo.oo Certification P~ SPY A Certification, an abstract from ~e marriage record issued under the seal of the HeaNh 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 9~• A Certification may be used ss proof that a marriage occurred. ~' and ^ Fee s10.00 Certified Copy P~ SPY A Certified Transcript indudes all of the items of information oxurring on dte original record of the marriage. A Certified Transcript may be needed where proof of preentsge and certain other detailed information may be required such as: passports. ve-'s benefits. court proc~dirrgs, or setMement of an estate. C PLEASE PRINT OR TYPE Name (Prat) (Middle) (Last) ~I /~ ~ G G 11 ~ Name (F~ (Midde) (I..as~ ~ ~ ~ l oom e a ,S c~c ,e , ~ - DYe r ~ f Groom's Age Bride's Age /~ or Date of , l ~j~ or Dale of j ~ ~ ~ //-- ~ , / Birth ` Birth CP /V (see, ~u ~) e ~ ~ k~ ' (~~, sS a ss Date of Marriage or Period Covered ~ / G1 G~' Z, M Bride Previously Married. Stela Name Search Used at That Time Place Where Place Where lkerrse Was . Marriage Was . Issued Pertonrred For what purpose is information required? Whet is your to person whose record is requested? 'v~Z~a~ . /C~P~ , ff self, orals "self.' ~~-~'~~ _ In what capacity are you acting? ff atlomey: Name and relationship of your diem to persons whose marriage record is required. S' Applicant Dale ~3D aol~ ~ Addr of Applicant lease print name and address where record is to be sent. DOH-301 (3/93) (PLEASE SEE REVERSE SIDE) to Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and Certification Fee $10.00 P~ campy A Certification, an abstract from the marriage record issued under the seal of the Health Departrnent. incdudea the names of the contracting parties, their residence at the time the license was issued es well ss date and place of tHrth of the txide and groom. A Certification maybe used as proof that a marriage occurred. PLEASE PRINT OR TYPE Name (Frsf) (Middle) (Last) .Q Groom ~ ~'`'~~` /~tWI~C ~. I~ ct! Groom's Age or Date of J o~ Birth IT o~ Residence (County) doom SD~Q-l~s a ~ t Date of Marriage or Period Covered n I - by Search ~K.~G~-s Place Where L Was ~~~ ~ ~ Search mrd ^ Fee $10.00 Certified Copy P~ cmpy A Certified Transcript includes all of the items of information occurring on fhe original record of the marriage. A Certified Transcript maybe needed where proof of pan3ntage and certain other detailed information may be required such as: passports. veteran's benefits. court proceedxrgs, or set0ement of an estate. Name (First) (Middle) (Last) of Bride ~~~e~cFr ~i,~-~v~) ~u~ i ~ a or cafe of ld " ~ ~ 7 Birtl~ (Smte) Residence (County) (State) '~ ~6 !C ,U /.~l~a ~ ~a~' ~ L w BLS ff Bride Previously p Married. 8tetis N 0 \~~`~ E ~ , ~ ~ t r7 ~ 5~ 1 used at That Time PMrce vVhere _ ° /` ~ ~ ~ ~ Per ~ ~ 0~tt-~ ~, r~s o e-. C ~~-l ~~ (~ ~l rror wnat purpose a mtomratwn requirea'~ ,.~--~.~ In what capacity are you acting? /~ .. ~ what ~ your relationship ~ person whose record ~ requested? ff salt, state ~elr.• ~X ~ % ~`~ ff atlomey: Name and relatior>ship of your client to persons wtase marriage record is required. ~O ~{~- ~ _~ ~ name~ed~-e to APR 2 6 201? DoH-~o, (sue) ~ ~ TOWN OF WAPPING (PLEASE SEE REVERSE IDE) TOWN CLERK r ~ g2 ~~~ _~~~~~~_ __ re~t~.cre_ _~_ Cer~i~~~~. C_o~~- D~_ vY~_ _ nn~-r~,_ ~i~-~ ivt or~P- ~ aD~c~sN1,~.t~ 1Yt~ rl.~i~Yt,2 ~` ` _ ~, . Application to Town/City Clerk Vrtal R Oecords Section EPARTMENT OF HEALTH for Copy of Marriage Record search ana ~ Fee s~o.oo Certification ~~ A Certification, an abstract from the marriage record issued under the seal of the Heatlh Department, inchides the rrarnes of the contracting parties, their residerrce at the tarre tine rrcense was issued as weft as daN and place ~ t~ of the bride and groom. A Certif cation maybe need as proof that a marriage occurrod. searoh and ~~ ~y ee $f o.oo ~ ~- A Certified Transcript inckrdes aN of the hems of information occurring on the origirrel record of the marriarge. A Certified Trerrecxipt may be needed where proof of parentage and certain other detailed irricrrnation may be required such ae: passportis, wjteran's bene5ts, court pr ' cgs. or setdemer~t of an eetale. PLEASE PRINT OR TYPE Name (Pest) (Middle) {Lasq Name (Find (Middle) (Last) I•. m. Cruz. ~~'. ~ le CI~nS~t,~ o~ t Groom's Age ads Age r.~.a~ ~~.~-, ts~- Hesiaence (~~ (state) c~3room %I1 I ~ ~ P-~-~C, I~'1 l~' g ;da ~i ~ ~ P-~?~ /~.~ tote of Marriage / // 9l1 ~ b ~ ands Prevrouely /!/9// gq~ or Period Covered Married. $tafe Narne by_Search _ Used at That Time vwr'°rirae (,~c~~'''~~ ~°~'~~~, ~ ~ ~ P~ r'ra° ~ ~~5 ~.`~-~~ 1`l".~~~ For what p<,rpoee a~.<< t .r vtmas rs your r~eteuorrstrip >b person whose record ie requested? ff self, she "setf.• ~ ~~ (~ In what capacity ars you acting? ff aporrrey: Name and relationstrip of your cNertt to persons ~ w`~~` whose rrrerriege record ie required. na~ese os nppecant - ~ t~iease pritrt Hems and address where record is b be aer-t. ~ 3 tY~c~v~~~ ~ Chn~v~ Ar ~C,ru,~. Cho~tM.s~~A Nth- O ~$a'f ooH~o, (s~> (P E SEE REV~EJRSE SIDE) ,__ ~~ (y ~ .JOAN M. O'CONNOR /`~~~~ ivy Pubic, Cammonxpailh of Mewol~ ~`~ `~~'j'~ ~y camera, r~e,~,eso,son ~ ~~ a?D ~~ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH Vital Records section for Copy of Marriage Record ~. Search and Certification ^ Fee 510.00 Cab'fied ~ ~ Fee $10.00 ~ SPY P~ SPY 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, inchidea the names of oocurting on fhe original record of the marriage. the contracting Parties. their residence at the time the licalrrse urea issued as well ae 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 A Certification be used ~ such ss: p~sports, veteran's benefits, c«,rt may proof ihat a marriage occurred. proceedings, or settlement of an estate. PLEASE PRINT OR TYPE Name (Frsh (Middle) (L:ast) Name (First) (Middle) (Last) of Groom K v ---~z~ISa~ B ~ 'Kri~~~'L V~'<~OY/A ~~(sDV~ Groom's Age " Bride's Age Birth ~ ' ~ - ~ ~ ~ ~ 7 ~ B~ of ~ ~ '- ~ ~ - ~ ~ ~j Residence (County) (State) Residence (County) (State) C~3roorn Fra n.k;li n ~G B tle ou~ICl,i n N . Date of Marriage ff Bride Previously or Period Covered (a - n , ~ O ~ ~ Married. Stsls Name Search '" ~ O` Used at That Tnne Place Where p~ yy~ I Was Wappi r~}ers dal Is ~ `f P ~la~~ - Fa.L Is OV ~~ For what purpose vvnar ~ you n~pa~an~ -~ whose record is requested? n self, atabe'self.' In what c^a_ppacity are you acting? ff attorney: Nine grid retationship of your client ro persons 0(.~Y ~-t'V.~ S • wtrose nrarnage t~ec~rd is required. re of Appticar,t laress of Applicant qo M v r~ ~~ Dpi v-e. Ze„lou-l vr~ P~. C . a~sq'~ DOH-ao, (s/eo) print name and address M . ~. G3[~C~C~UMf~D 3EE >~~~ TOWN OF WAPPINGER TOWN CLERK to be sent __ s Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH ~;~ Records Sion for Copy of Marriage Record seanrn and ~ Fee s~o.oo Certification ~~ A Certification, an abstract trorn the marriage recond issued under the seal of the Health Department, inCh~dea the names of the contracting parties, their residence at the time the lica~rrse was issued as well as date and place of birth of the bride and groom. search and ~ Fee $~ o.oo Certified Copy ~ ~y A Certified Tranecxipt includes ati of the items of information occurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed inforrrtadon may be A Cerlfication ma be used as. such a$: ~~• veteraf-'s benefits. court y Proof that a marriage oxurrod. prooeedrn~, or eetfiement of an estate. !~, PLEASE PRINT OR TYPE DOH-3ot (s/gci) (PLEASE 3EE REVERSE SIDl7 ,~ 1 Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marria a Record Vital Records section y Search and ~, ~ Fee s~ o.oo ~ ~ Fee $~ o.oo P~ spy ~ v ~ per copy A CerhficaGon, an abstract from the marriage record issued under the seal of the Health Department. includes the names of the contracting parries, their residence at the Erne the license was issued as well es dam and place of birth of the bride and groom. A Certification may be used ~ proof that a marriage occurred. j PLEASE PRINT OR TYPE A Certified Transcript includes aq of the items of information occurring on the original record of the marriage. A Certified Trarscript may be needed where proof of parentage and certain other detailed information may tie required such as: passports, veteran's benefits, court proceed"mgs, or set0ernenc of an estate. Name (Prat) (Middle) (Lasq Name (First) (Middle) (Last) Groom ~ C(,2~-- ~tS~ ~~~ Bride ~Pl ~.~~ M ~l ~S~ rl Groom's A or Dam of ~ ~~ ~~ p / ~ ~ ! or Dale o~ ~ ~ ~ ~"~~ v Birth girth Residence (County) (State) Residence (County) (S1~e) of :Groom ~~-CS S /" ~ ~ Bride ~'f~SS /~- Date of Marriage ff g~ p or Period Covered /~ ~ ~ b ~ ~ Married.. State Name Search Used at That Time Place Where PMrce Where License Was Marriage yy~ ' Issued Pertormred For what purpose is information required? What is your relariorrehip to person whose record is requested? ~ / t-O~fzs ~`~GJt'-. t- ~ t 1a0~ ~ C~`fc. ~/'LJ , stafs'self. ~~ In what capacity are you acting? H atbmey: Name and reiariorrship of your client to persons whose marrie~ge record is required. S' of Applicer-t \ ~ Dade ~ O~~ ~ ~`r l~ Address of Appl~ant Ple~sse print name and address where record is to be sent. c..t.~ c~~ ~ ~Y ~~~~-~ DOH-soy (sl~ci) (PLEASE SEE REVERSE SIDE) Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers Apply to: Cert~cation Unit Vital Records Section P.O. Box 2802 Albany, NY 12220-2602 Albany: City Clerk, City Hall, Albany, NY 12207 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 Yonkers: City Clerk City Hall Yonkers, NY 10701 2. License Issued in New York City Apply to the Borough office of the New York City Clerk that issued the marriage license. The location of these offices follows: Manhattan - Municipal Building, New York, NY 10007 Brooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 1908-1913 are on file with the Manhattan office) 1760 Grand Concourse, New York, NY 10457 Glueens - (Records prior to 1898 are on file with the New York State Department of Health) 120-55 Glueens Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1888 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Departrnent of Health. ':~ r '~ f NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Search and Certification ^ Fee $10.00 P~ ~Py A Certification. an abstract iron the marriage record issued under the seal of the HeaNh Department. inchidea 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 9~• A Certification maybe used as. Proof that a marriage ocxun ed. Application to Town/City Clerk for Copy of Marriage Record Search and - Certified Copy Fee $10.00 SPY A Certified Transcxipt includes atl of the items of information oocuring on the original record of the marriage. A Certified Tranecx~t may be needed where proof of parentage and certain other detailed information may be required such as: passports. ~re~rar's benefits. court proceedrnga, or settlement of an estate. PLEASE PRINT OR TYPE Name (Frs>j (Middle) Groom C~S'~ ~ (Lash) ~ Name (FirsQ (Middle) (Last) ~j ' 1 ~~ ~ ,~ Bride S>~~,~".L~~i--1 ~~~ 1v C3room s Age B~ ~°~ dl f23 f-7~ Bride's Age ~ °~ o~ ~as-/ ~~ e Resrdence (County) 0 ~ u'~ ~ ~ (State) N Residence (County) (S~) °f oom - . Bride - !7v'~C~,~S N Date of Marriage ~ ~ C7 / l~ ~I ~ ff Bride Pre~riously Married; 8tafe Name ~,, C 1~ C ~~~ rl e used afThat tans ' ~ Place Where ~y~' Was ~6v.1~'1 llt` 1~~~ -~v'S P~ Where 1 Marriage Was ' IX n M ~~ ~Tl Perbrmed Y ~U For what Purpose is irdormation required? a 1 SAC ~ r~ C~ ~ Whart is your relatiorrst,ip to whose record ie /1 re4u~ted? ffself.atale'aeif.' j r c ~-~ ~-' a r~ ~ Inwhat capacity are you acting? ff attorney: Name and retati onatmp of your client to persons wNoee marriage record is required. S' of ~, A rasa of Applicant 12 Z C~, e ~S ~-a ~ ~ Pkase print name and address where record is to be sent. S~rv'-D2 ~ C~~ o~nc~ ~~-~~~~9 -cam s ~2~~s, ~ ~~~o i22 cG,-etS~~ C~ ~,~~, ~ s ~ ~ rs ~ y , 2S9 ~ DOH-301 (3/tiCi) (PLEASE 3EE REVERSE SIDE) 3/12/12 Town Clerk Town of Wappinger 20 Middlebush Road Wappingers Falls NY 12590 To Whom It May Concern: I Mary Alice LaDue am requesting a copy of my marriage license/certificate. Please return to me at my place of employment. Lincoln Financial Group, 100 N. Greene Street, Greensboro, NC 27410 Mary Alice LaDue ~ rM~rGh 12 Zc~ ~ a (Y~ ~ r y f~-l ~ c ~ ~P(~Pared ~-~re M2 ~~,~~;~ NATAIIE S. HAVES Notary Public GuUford County NortA Carolina L-o~,c~.\u e S c ~ 0.'ZC~ S ~ fl~~-r ~l Nc . flc.ktl~w1Q~15'~n~ 21, 2016 NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk Vital Records Section for Copy of Marriage Record R~,~~~ Search and Certfication ^ Fee $10.00 I Search and per copy Certified Copy ~ee $10.00 IIII ~~II err 111III 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 ~e bride and groom. A Certfication may be used as. proof that a marriage oxurred. 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 detaileda~formafion may be required such as: passports, veteran's benefits, court proceedings, or settlement of an estate. w. PLEASE PRINT OR TYPE Name (Prat) (Middle) (Lest) Name (First) (Middle) (Last) of Groom c; d ~ r~ G f~enwood ~a#~ u ~e.. of Bride ~-0. 1y `l.c,~ l~-~ v `2. Groom's Age Bride's Age or Date of ( or pate of Birth (> OW I l Birth t 1 t lat7 Residence (County) (Slate) Residence (County) (State) Groom ~ 1 C.. Bye Guy l ~rd- ~ Date of Marriage If Bride Previously or Period Covered Married, State Name b Search U l y o2 Used 8t That Time Place Where Place Where Is Was ~w 6~ Gve~ n er e ~ vwn a~ Gc~ ~n e.~^ For what purpose is information required? What is your relationship to person whose record is requested? ~ a~ n'~a.r e.fn If self, state "self.' ~S~/~ Dr hr~lfh be.n~~~s In what capacity are you acting? If at~mey: Name and relationship of your client to persons ~S~ `~ whose marriage record is required. ~ m Sign re of Applicant Date Address of A cant ~1 " ~rr v2 / - ~ Please print name and address where record is to be sent. l G ~ ~ r err- C~,S ~~ L r n c~ !n Ana ne.~ 2. /<JC ~,`7~l!(~ S bvra ~' ti2en ~u~ - TP l~. s ~ ~ ~~ n ~ , , , ~-- l .s a ~ ~.~ 4 ~0 . DOH-301 (S/93) . (PLEASE 3EE REVERSE SIDE) "~""!~!'~ DRIVER LICENSE 96706598 rnpr wtcE tAOUE 'x117 FERNCREST Dp DpEENSBOpd NC 2710-6312 dass:C eMUS:NoOe math tssueG Ol2B~20/1 expirea:07-15~[t6 r satCF M:64t eyes: flpO hey bitlMete: fj_ y_._ 07451!60 _ ++~"~ ~I ~_~ . ~ dyp1dn11,101 Pp~'A dn¢+°~~Cyy~dWD1a~.007 Pan7° ~~ apwi~d4 ~~ ~cmW+e e..wu'c tcaaa"ts r NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk ~;tal Records section for Copy of Marriage Record search and ~ Fee s~o.oo Certification P~ SPY A Certification. an abstract from the marriage record issued under the seal of the Heald Department, includes the names of the contracting parties. their residence at the time the license urea issued as well es date and pl~e of birth of the bride and groom. A Certification may be used as. proof that a marriage oxurred. Search and ~;~ spy ~ Fee $~ o.oo per copy A Certified Transcript includes aA of the items of information oxurring on fhe 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 ~ estate. E D'. PLEASE PRINT OR TYPE Name (Prat) (Middle) (Last) Name (First (Middle) (Last) G Dorm c.~.~- ~ ~ ~.t~ ~ Bye n Il~c~ `M I~r n ~c IC Groom's Age 3 3 Bride's Age Residence (County) (State- Residence (County) (State) Groom ~J~-~,t S ~ aide ~~-C~h.kS 5 ~' Date of Marriage ff Bride Previoush- or Period Covered ~ 2 O D 2 Married. State Name Search r Used at That Time Place Where Place Where I was ~ ~ ~ s .-~:.- is P w - I Is ~~~ For w h et purpose ~ information required? What is your relatiorrstap to person whose record is requested? ~ t 1. ~ p~ O~ YYl p.,r t i Q ~ ~ C~ h ~ If self. state 'self." In what capacity are you acting? ~ ff attorney: Name and relatiorrsfiip of your client to persons whose marriage record is required ~m O~ ~ n . Signature Applicant Dale `~ ~~ ~~1 c ~ 3 -12 - 12- Address of App~t U „ r Please print name and address where record is to be sent. avy S olcl t,~as1~=,~~ ~ r<-C `cis-~-~ ~ /~ 5 ~c r . C~ c~" Z- l I .S-7 DOH-soy (sf9c3) . (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Su I Form Vdal Records Section - Registratiot- Unit PP y SEND YOUR ORDER TO: ~ MAILING LABEL Vital Records Section New York State Department of Health Registration Unit P.O. Box 2602 Albany, NY 12220-2602 Date order mailed: (Please print or type, Do not use slam .) District No(s). Name Title Mailing Address (Street or PO Box) (Cdy, Town or Village) Zip Code DOH ORDER #: NAME OF FORM Form No. (iuentity NAME OF FORM Form No. Ctuantity REFERENCE MATERIALS APPLICATION FORMS Vital Records Su I Form DOH-2230 2 Search of Birth Records DOH-296A (Automatically Supplied with Order) Search of Death Records DOH-294A Geneal ical Searches DOH-1562 Search of Marna a Records DOH30t Search of Dissolution of Mama a Records DOH-295 BIRTH FORMS Certificate of Live Birth DOH-tsq MARRIAGE & DISSOLUTION OF MARRIAGE FORMS Marriage License and Affidavit DOH-98 Electronic Birth Certficate Work Booklet (English) DOH-2t84E Getting Married in NYS -Information Booklet PAG~210 Electronic Birth Certificate Work Booklet (Spanish) DOH-2ta4s AIDS Fact Sheet PAG-0245 Supplemental Report of Given Name (VS-31) Application for Correction of Certificate of Birth DoH-st DOH-297 Afidavit for Correction of Marna a Certificate of Consent Month R rt of Marria a Licenses Issued DOH-ta27 ppft.~g DOH-963 Instructions for the Correction of a Birth Certificate Certification of Birth (VS-10) [8.5 x 11 inch form] No Record Certification -Birth S-11) Certification of Birth (Foundling) Certified Transcript of Birth Re rt of Voided Certification of Birth Forms DOH-29r DOH-2248n DOH-3656 DOH-2676 DOH-2673 DoH-2622 Certificate of Marriage Registration (VS-12) Retum Envebpe (Limit 24 per year) (VS-'7~ No Record Certfication - Mama a VS-13 Certificate of Dissolution of Marriage (VS-140) Certfied Transcript of Marriage DOH-130 DOH-2386 ppFt~4 DOH-2166 DOH~t22 Report of Voided Certified Transcript of Birth Forms Birth Information Release Form DOH-2824 AUTOMATIC TRANSFER BINDERS OOH-3965 Birth -for bindi 500 Certificates DOH-001 Death -for bindi 500 Certificates DOH-002 INDEX PAGES DEATH AND FETAL DEATH FORMS Certificate of Death Birth - kx~se leaf es for binders DOH-2392 Burial-Transit Permit (VS-61) DOH-1961 Death - ktose leaf pages for binders pOl.l.~93 DOH-1555 MISSING CHILDREN Application for Correction of Certific t f D a e o eath Instructions for Correcting Death Certificate Medicat~Burial Death Correction Re ort VS 64B DDH-299 DOH-298i Notification of R oast for Missin Child's Birth Certificate DoH-0895 . p ( - ) Undertaker's Request for Disinter Bod (VS 6T DOH-1999 Physical Description Form ~ DOH~3896 y - ) Report of Autopsy (VS-69) DOH•2699 Certfication of Death (short form) DOH-3657 DOH ADOPTION REGISTRY No Record Certification -Death (bS-63 -~25 Information Packet PAG-0101 Certificate of Fetal Death -Spontaneous Termination Certificate of Fetal Death -Induced Termination DOH,9405 DOH-3547 licatton -Ado tee R istration Form Applicabon -Birth Parent Registration Form DOH-3o DOH-4065 Monthly Count of Report of Fet l D h DOH-3548 a eat Report of Voided Certification of Death Forms Certified Transcript of Death DOH-2179 DOH-2623 DOH~144 MISCELLANEOUS Appointment of Registrar Appointment of Sub-Registrar DOH-1556 DOH-2457 DOH-2230 (05/06) Page 1 of 2 Ordering Vital Records Forms Registrars and clerks: Refer to the Ordering Schedule to determine the designated ordering point for your district. Mail your orders so they are received at the Department of Health within the designated week for the County where your district is located. Orders received before or after the designated week will be held for processing until the next cycle. When ordering forms, please: / Send one order each month. Ordering Schedule Find the county in which your district is located. Send your order so it will be received by the Department of Health during the week of the month specified for that county. NOTE: The First Week of the Month is the week in which the first Monday occurs, the Second Week corresponds to the second Monday, etc. First Week of the month: Albany Chenango / Use the current Vital Records Supply Form, Allegany Clinton DOH-2230. Broome Columbia Cattaraugus Cortland / Adhere to the schedule. Cayuga Delaware Chautauqua Dutchess / Plan ahead. Don't wait until you are out of Chemung Erie forms to place your order. / Maintain athree-month supply of forms. Second Week of the month: Over ordering depletes the Health ' Essex Lewis Department s inventory and causes Franklin Livingston shortages. Fulton Madison / Order by mail. Telephone requests will not Genesee Monroe be accepted. Greene Montgomery Hamilton Nassau / Fill out the Vital Records Supply form Herkimer Niagara completely. Jefferson Oneida / Specify the actual number of forms needed. Third We®k of the month: Do not order packages. Onondaga Rensselaer / Make sure your district number and Ontario Rockland address are legible. Orange St. Lawrence Orleans Saratoga / Specify "Vital Records Supply Form" in the Oswego Schenectady lower-left corner of your mailing envelope. Otsego Schoharie Putnam Schuyler Send your orders to: Fourth Week of the month: New York State Department of Health Vital Records Section/Registration Unit Seneca Warren P.O. Box 2602 Steuben Washington Albany, NY 12220-2602 Suffolk Wayne Sullivan Westchester Tioga Wyoming Tompkins Yates Ulstef DOH-2230 (05/06) Page 2 of 2 ~% NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk ~~ Re~rds sermon _ for Copy of Marriage Record searcn and ~ Fee s~o.oo Certification P~ ~Py A Certification, an abstract from the marriage record issued under the seal of the Health Deparhnent, includes the names of the contracting parties, their residence at the time the license was issued as well es date and pl~e of birth of the bride and groom. A Certification may be used as proof that a marriage oxurred. seanrn and Certified Copy ^ Fee $10.00 per copy A Certified Transcript includes ap 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 benefit, court proceedings, or settlement of an estate. ~~'~ I PLEASE PRINT OR TYPE dle) (Last) Name (i g~0~ (Mid ~ t Name (First) (Middle) (Last) Groom / t7 ~i C L e ide r;oN ~ /~ l~ C ~ Groom's Age Bride's Age or Date of Birth or Date of :l Beth / 2 0 `z Residence (Courriy) (Sfatie- Residence (County) (State) a oom L..1 - ~-, ! s /~- L B de w f~ ~Gf 1 ~`~ l ~s /~ Date of Marriage ff Bride Previously or ed ~ Married. Stat3e Name _ Llaed at That Time Place Where Place Where Issued Was / " / [ '/¢- , Per d ffi N'r- ~i- ~'i ~' L l~ For what purpose is information required? What is your relationship b person whose record is requested? s ~ If self, ett'self.• ~ ~~ f-c s ~ r ~~s In what capacity are you acting? ff attorney: Name and retationship of your client to persons whose marriage record is required. Signature of Apptic~t Dale ` ~ ~ > 3 Addr of pplicant 6 6 W FF 5 ~, r` ~`'~ `f~ ~`' ~ f Please print name and ad rasa record is b be sent. ~ e o r~f e j~ G~ J~ ~o ~~ ~ t~ ~ ~60~ ~ ~ w~~~ ~ "~ ~ t Pa_I~ /~-~/ 1 ~~6~ Doti-eoi (s/93) ~ . (PLEASE SEE REVERSE SIDE) /` 1 f C) .~ ' t; Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH Vital Records sectieon for Copy of Marriage Record search and ~ Fee slo.oo certification ~~ A Certification, an abstract from Ste marriage record issued under the seal of the Health Departrnent, 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 oxurred. Search and Fee $10.00 certified copy LLJJ per copy A certified Transcript includes aq of the items of information oxurring on the original record of the marriage. A Certified Transcript may be needed where proof of parentage and certain other detailed infomnation may be required such as: passports. veterar-'s befits, court prOCeedingS, or S@Ltiement of 8n estate. PLEASE PRINT OR TYPE Name (Prat) ('ddle) (Last) Name (F ist) (Middle) (Last) I ~) Groom ~ 0~~1 -~ v (1 ~ ~ ~"'`- ( i Bride (Nl c S h.R_. Groom's Age Bride's Age °a~ of ~"~ - ~ S ` ~ ~ e ~ ~ CI _ ~? - 7 ~ B Residence (Couunty_) (St~ate^) ` ~~7~ ~ Residence }~ (County) (State) ~/ ~ ~ L Groom V ~ V 'SS C~ Bride ~:/ (/ Date of Marriage M Bride Previously or Period Covered `~ ~ ~ l Married. State Name search cf used at That tans Place Where License Was '/~ ~ l L r t'~- ~! ~' Place Where Marriage Was ~ i '~°" ~ , Issued V Per(onned For what purpose is inbrrnation required? What is your relationstr~ to person record is requested? Itself, staie'SetL' ~ ~ / In what capacity are you acting? tf attorney: Name and relationship of your client to persons whose marris~ge record is required. Signature of Appacar-t Date ~~ l'"' ~~ Address of Applicant Please print name and address where record is to be sent. wA~- ~i~s ti~ ~ a2 Fecl~ s'Fvw~ Co tt~`~- io ~ a-S - ~o ~ ~ ~ k t°e,os~ ~ /ut 6 i yG o 3 DOH-301 (8)90) (PLEASE 3EE REVERSE SIDE) Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers Apply to: Certification Unit Vital Records Section P.O. Box 2802 Albany, NY 12220-2602 Albany: City Clerk, City Hall, Albany, NY 12207 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 Yonkers: City Clerk City Hall Yonkers, NY 10701 2. License Issued in New York City Apply to the Borough office of the New York City Clerk that issued the marriage license. The location of these offices follows: Manhattan - Municipal Building, New York, NY 10007 &ooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 1908-1913 are on file with the Manhattan office) 1780 Grand Concourse, New York, NY 10457 Glueens - (Records prior to 1888 are on file with the New York State Department of Health) 120-55 f~ueens Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1898 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. l t PLEASE PRINT OR TYPE Name (Firs>) (Middle) (Last) ~ Name (Fast (Middle) (Last) Groom ~ ~~ ~lC~ Bride --- Groom's Age Bir~ e ~ ©q a~ ~ Bride's Age ~ °~ ~ 01 aal ~ 9~ Residence (County) (State) Residence (County) (State) of ~ Groom ~ Bride Date of Marriage ff Bride Previously or Period Covered D ~1 1)~ ~1 ~ ' ~ I pt / ~ Nettled. Staffs Name search 1 p , , used at That cane P,;~'"w `Tot,~n ~}-c~ l`~ t ` , 1 ~ ot,~n ~ 1 ~ l ~s ~u ~ Issued l r Gtl~/S N` ! I Periom~ed For what purpose is information required? Wtiart is your relatiorrsh whose record Ls requested? C ,,, ,n„ ,,, S , _ _.. „1... If self. staffs ~eelf.• ~ In what capacity are you acting? ff attorney: Name and relationship of your client to persons whose marriage record is require~J. Signature of A icar-t Dais D~~ ©9 ~a Address of Appl° t 5~5~1~~ rest Please print name and address where record is to tie sent. ~ s~ , . ~ ~ DOH-301 (3/93) . (PLEASE SEE REVERSE SIDE) Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH • ~;~ Re~rds for Copy of Marriage Record search and ^ Fee $10.00 Certification P~ SPY 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 ~ date and place of birth of the bride and 9~• A Certification may be used as. proof that a maniage occurred. Search end Fee $10.00 Certfied copy ' Pef SPY A Certified Transcript includes all of the items of information occurring on tl~e 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 settiernent of an estate. PLEASE PRINT OR TYPE Name (First) (Mi(d~dle) --``(Last) Name ` (First) (Middle) (Last() Groom S~e,o~,~e,~n \ \ ~ ~C~,r~C,U' Bride . ~~nns©~ ~~ ~ ~~~r~~ ~~ Birth ~ ~, ,- \ ~ - \ si enc e Re d (County) ~ _ ~ ~ ~ "~~ l ~~ ~ C' ~C~ Date of Marriage e ~ or Period Covered by Search ,-~ // ~.\ l ~ v~ P _ C~ (State) or Date of license was Issued i, Residence (County) (State) °~ ~~~e~~s ~e~ `~~-~ Bride ff Bride Previously Married, Stems Name 2-. Used at That Time e~S ~~~~.5 PeRr dwas ~~~ ~.v. ~ uv`~ For what purpose is irrfonnation required? ~ S ~~ In what capacity are you acting? What is your refationsh~ do If self, state's~f.' r--~ If attorney: Name and relationship of your client b persons whose marriage record re required. of ' 2~ / 2 Address of Applicant Please pent name and rasa where record is b be sent. ~~~~0~~ D D DOH-301 (3/93) (PLEASES REVERSE SID~~ 5 2012 T~wN ~F WAPPINGER Taws CLERK Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH ~~, Re~rds for Copy of Marriage Record Certification ^ Fee 610.00 ~ ~ ^ Fee $10.00 P~ cePY Per cePY A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information under the seal of the Health Department, includes the names of occurring on the original record of the marriage. the contracting parties, their residence at the time the li~se was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of groom. parentage and certain other detailed information may be required such as: passports. veteran's benefits, court A Certification may be used as proof that a maniage occurred. proceedings. or settlement of an estate. PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (First) (Middle) (Last) Groom ~ ~ ~ ~ ~~~ Bride ~ ~ l ~` ~. L. ~,- Groom's Age Bride's Age e ~ 9 ` & Date of ~ // / ` Birth Residence (County) (State) Residence (County) (State) C~aroorn ~~ ~~ s ~ Bide ~ rx7crt mss N Date of Marriage ff Bride Previousty or Period Covered Married. State Name ~" ' ~ f= Search l f lJsed at That T ime ~I J T t L ~ Place Where Place Where ~ License Was Issued _ l bLcsl~ lg,~ ~lGI~ ~~Iti'~EIZ.S ~~~-$ Marriage Was Perfom-ed / ~ L- vl ~-~14~~ aF,GIJl4~'~1W6ER..S I ~t~. For what purpose is information required? What is your relationship 1n person ff self, 8tate'self.• s, Ci~i'i.d..i ~~~r. SIT/ ~hA.iihliST.P14T/tJ ~-~~ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Re~rds Section Search and Fee $10.00 Certification P~ campy A Certification, an abstract from the marriage record issued under the seal of the Health Departrnent, includes the names of the contracting parties, their residerwe at the time the license was issued as well as date and place of birth of ffre bride and groom. A Certification may be used ~ proof that a marriage occurred. Search and ^ Fee $10.00 Certified Copy per copy A Certified Transcript includes aB of the items of information occurring on the original record of the marriage. A Certified Transcript maybe needed where proof of pererrtage and certain other detailed information may be required such as: passports, veteran's benefits. court proceedings, or settlement of ~ estate. PLEASE PRINT OR TYPE Name (Prat) (Middle) a st) (L Name (First) (Middle) (Last) Groom '''~) ~ ~ i~~ tM ~ , Q U `' ~ Bride ~C ~~rl~' ~; C y'1 ~~t%'~ Groom's Age Bride's Age air ate of _ J Z ' ~ D ~ ~ 2 - Z 3 ~- ~ 3 Residence (County) (State) Residence (County) (State) Groom ,vv'TGh.eS -''L- - Bnde JAL"TG~/e SS /'~'~ - Date of Marriage ~ ff Bride Previously ~ 1 I -" l ~ 'II s '-~----~~.__~t.._.. earch b UsedThat Time Place Where Place Where License Was ~~ ~ n `~ 1 Issued ~ / 7/H C ~ ~ G/~ Mamage Was I,~6 I/~ Pied s information required? For what purpos e i What is your relationship to person whose record is requested? ~ %/ I ~ ~ y / ~ ff self. staie'self.• Se (1~ In what capacity are you acting? ff sttomey: Name and relationship of your client to persons ~~ ~ ~ whose marriage recd is required. /L /~ Signature of Appl' t ~ Dais ~Z ~ I ~/- I/ ~z~ -, C9 Address of Applicant Pbase print name and address where record is to be sent. I S ~e ~ S~ ;~ DY ~ V~l~ ~~. ~"~ ~ ~ S ~/` " l 2 "~ ~ J DOH-301 (8/903) (PLEASE SEE REVERSE SIDE) Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marria a Record vital Records section AY J Search and ~~( F~ $10.00 Certification /U P~ ~ A Certification, an abstract from the marriage record issued under the seal of the Health Departrnent, includes fhe names of the contracting parties, their residence at the time the license was issued as well as date and place of firth of the bride and groom. A Certification may be used ~ proof that a marriage occurred. Search and Fee $10.00 ~ COQ ~ per copy A Certified Transcript includes all of the items of information occurring ~ 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 settiement of an estate. PLEASE PRINT OR TYPE Name (Frs~ (Middle) Last) ( Name (F~ (Middle) ~~ _(~~~n~ G oom "~© r~.S ~ ~ n , ` `o ~ Bide ~' ~w'IJ (~~-,•-,IFCY Groom's Age Bride's Age or Date of Birth 1 a ~ or Data ~ Birth Z© 3 Residence (County) (State) Residence (County) (State) Groom ~.~ S I ~ Bride C ASS Date of Marriage ff Bride Previously or Period Covered Married. State Name Search , ~ ~ Used at That Time Place Where Place Where . License Was Issued l 4 1~-1- O >D Marriage Was `n Pertonned ~ ~ p `` For what purpose is information required? ~~~ What is your relationship b person whose record is requested? g self, stela "suf.' ~ \ C'` In what capacity are you acting? -~_~ ff attorney: Name and relationship of your client b persons whose mariage record is required. DOH-301 (~~) . ~ p~..~~(PrfJCSE SEE REVERSE SIDE) ~~ r Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section ~~~ ^ Fee $10.00 ~ y ^ Fee $10.00 P~ cePY Per cePY 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 fhe 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 msy 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. proceedmgs, or settlement of an estate. PLEASE PRINT OR TYPE Name (Frs~ (Middle) (Last) Name (First) (M idd le) t) Groom ~l/1 !~' i Q 1~-~- ~ v ~ ~_ Bride / / _ ~` 1. G(~ [~lJ~ ~ '~--'1 v~L Groom's Age or Date of ~ f ~ (~ ~ ~ Q Bride's Age or Dam of J ~ ~. '1 ~ Birth Birth Residence (County) (State) Residence (County) (State) In what capacity are you If eta whose Persons Addrbss.et~Applicant Please print name and address where record is to be sent. DOH-301 (8/93) (PLEASE SEE REVERSE SIDE) t NYS Department of Motor Vehicles INTERIM LICENSE 917888675 ~ cie:e D Rextrietionx NONE Enaenemenb NONE stains terminstex nn 12 / 2 6 / 19 Probation Date NONE s This document expires on 0 5 / 0 8 / 12 RIVERA ' ~' ADELAIDA 12 GALE DR POUGHKEEPSIE NY 12603 se: F eyex BR at. 5 6 Birtnaate 12 / 2 6 / 7 7 Additional Restrictioro NONE sl X . ~ ; Here '-- • Keep this document until you receive your Photo Document MV-1 (4/11) PART Y NEW YORK STATE DEPARTMENT OF HEALTH vital Records section Application to Town/City Clerk for CiDDV of Marriana Ror~~rrl Search and Certification ^ Fee $10.00 f~ SPY A Certification, an abstract from the marriage record issued under the seal of the Health Departrnent, 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 or 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) (~ Groom ~~ y~,~C~C~(~J~ - Bride ~~r~L'~ rl`(r°Y~1 ~ . ~ n V~ ~r ra ~A) .~ v- Groyom's Age ~ \\ ~ Q\ Bnde's Age ~ q /~ 2 l/.~/~`/ B~rY 1 e ~ ~v ~ ~ ~ \~ ~ \ B~ ~ ~ n d ~ A A 1 \!0 AN' / 7 ' 1 ] ~I Residence (County)` (State) Residence (County) (State) of ~ \\ of Groom U ~ "~ Bride ti Date of Marriage ff Bride Previously or Period Covered Married. State Name Search 2 Used at That Time Place Where \ Place Where C Issued Was ~(~ ~ ,t ~/1 (~~ \ ~ n t~ ~ Perforrned as _ \~C), ~ ~~ f~~ v~ (~ l) V'~`~ For what purpose is information required? What is your relationship to whose record is requested? ~ If self. state'self.' In what capacil)r are you acting? ff attorney: Name and reiatiorrship of your client to persons ~~\("') whose marriage recoM is required. Signature or Applicant Date ~ ~~ zc,~Z Address of Applicant -, l Please print name address to be sent. tea, ~~ ~ Fa-~~s 1 ~t , ~ ~ 2S~ DOH-301 (3/9Ci) (PLEASE SEE REVERSE SIDE) __ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Co of Marria a Record vital Records section py search and ~ Fee st o.oo certification p~ ~- A Certification, an abstract from ttie marriage record issued under the seal of the Health DeparUnent, inchides the names of the contracting parties. their residence at the time the license was issued as well 88 date and place of birth of the bride and groom. A Certification may be used as proof that s marriage occurred. searct, and a Fee s, 0.00 certified ~ p~ spy A Certified Trarrscxipt includes aN of the items of information Occurring On the Origln8l reCOrd Of the nlafrlage. A Certified Transcript may be needed where proof of parentage and chin other detailed information may be required such as: passports, veteran's benefits, court prooeed'mga, or settlement of an estate. ~,i, ~ 'I PLEASE PRINT OR TYPE Name (Prat, (Middle) (Lash Name (First) (Middle) {Lest) of ~ Groom James Dewitt Robinson BrldA Elizabeth Mary Grasso Groom's Age Bride's Age or Date of or Dale of Berth February 17, 1962 Bj~ May 19, 1964 Residence (County) (8tate) Residence (County) (State) d ~ Dutchess County New York ~ Dutchess County New York Date of Marriage ff Bride Prevaus~ or Period Covered Married, Stale Name Search February 14 , 1982 Used 8t Thal Time N/A p18CeyVherePossibly the Town of Wappingers Court PlaceVVtlere License Was House but never received a copy W88 Town of Wappingers Court House ~~ PerfOrrrled FOr what purpOSe IB InfOmration regUlred~ ati0f18t11p t0 p8r80n WhOee reCOrd IS regUSeled~ What Is yOUr fA l 11~ ,~ { If aClls State OQII.~ Obtain California Driver's license Self In what capacity ere you acting? H atlomey: Name and retetionship of your client to persons whose marriage record is required. Self N/A S' re Of Dew Addr of Applicant Please ~ t name address where record is to be sent. 130 athy Drive Elizabeth Robinson Newbury Park, CA 91320 130 Cathy Drive Newbury Park, CA 91320 DOH-90t (3/99) . (PLEABE 8EE REVERSE 81DE) CALIFORNIA ALL-PURPOSE CER'TIFICAT`E OF ACI~NNOWLEDGMEN'T State of California / I County of VfinTu~ On n (~ Z ~' ~~Z before me, ~ ~~ Le ~a insert name i personally appeared ~~ ~"Gi bC ~ I(,0 ~ sOr'~ who proved to me on the basis of satlSfactory evidence to be the person" whose name is/tee subscribed to the within instrument and acknowledged to me thatl~e/she/tkey executed the same in 's/her/t~o4r authorized capacity(ies), and that by l~s/her/#~ir'signature(s) on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. COMM. #1820876 z ~ ~~ o Notary Public • California o WITNESS my and and official seal. Z Ventura County My Comm. Expires Nov. 27, 2012 (Notary Seal) Signature of Notary Public ADDITIONAL OPTIONAL INFORMATION DESCRIPflTION OF THE ATTACHED DO fCU_MENT ~t~TO^ ~ h, ~ UU (Title o description of attac d doc ent) to f Co Iti o~ (~.('Pia+~e ~~- (Title descri 'on of attached ocument continued) Number of Pages ~ Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ^ Individual (s) ^ Corporate Officer (Title) ^ Partner(s) ^ Attorney-in-Fact ^ Trustee(s) ^ Other INSTRUCTIONS FOR COMPLETING THIS FORM Arty acknowledgment completed in California m:~st contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is ~' a document is to be recorded outside of Cal(fornia In such Instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in California (i.e. cert~ing the authorized capacity of the signer). Please check the document carefully for proper notartal wording and attach this form ~f required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer{s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notazization. • Indicate the correct singulaz or plural fom~s by crossing off incorrect forms (i.e. lis/she/; is /are) or circling the coaect fomrs. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re-seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. w Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com • y -_ Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record vital Records Section Search and Fee $10.00 Search and ^ Fee $10.00 Certification ~ cepy Certified Copy per copy A Certfication, 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 oxurred. proceedings, a settlement of ~ estate. >., PLEASE PRINT OR TYPE Name (First) (Middle) (Last) Name (Fast) (Middle) (Last) om - ~ t~se. M.U~-fi~t B~,e V~1 I c' M o.r i e~ M Groom's Age Bride's Age or Date of I1c~ I' 2 Birth V U ~ Births ~ Residence (County) (State) Residence (Coup ) (State) ~c3room ~~ SS ~- t B ~ ~~.1 I S S Date of Mariage ff Bride Previously or Period Covered ~ ~ ~ Z I (~ Married, State Name b Search Used at That Time Place Where Place Where ,~ Was W ~n ~FQtIS -~~ . ~`"as i ~ -~uI~S N For what purpose is information required? What is your relationship to person whose record is requested? ' ' '~~~ SoC{Ct,~ ~ If self, state "self.' ~~~ In what capacity are you acting? If attorney: Name and relationship of your client to persons G„ , ~ wrhose mariage record is required. Signature of pplicant Date ~b 37 1 ~ Address of Applicant Please print name and address where record is to be sent. NICE M.u.~q ~N-c~~e.. Mu~~~~t w~P I r~..vs S N~ IZS 1~S W~Pp ~ n~j.~ys ~ls N~ 1 zs~c~ DOH-301 (3/9Ci) (PLEASE SEE REVERSE SIDE) Where to Apply for Record of Marriage f. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present Apply to: Certrfication Unit Vital Records Section P.O. Box 2602 Albany, NY 12220-2602 * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers 2. License Issued in New York City Albany: City Clerk, City Hall, Albany, NY 12207 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 Yonkers: City Clerk City Hall Yonkers, NY 10701 Apply to the Borough office of the New York City Clerk that issued the marriage license. The location of these offices follows: Manhattan - Municipal Building, New York, NY 10007 Brooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 1908-1913 are on file with the Manhattan office) 1780 Grand Concourse, New York, NY 10457 Queens - (Records prior to 1898 are on file with the New York State Department of Health) 120-55 Queens Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1898 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. ST ,~ i~: eat lei ~ss cuss I` ~ T W ~ ~~ ~~ii '~. i ~ ~~ , . • ~~ 6 y,, NEW YORK STATE DEPARTMENT OF HEALTH Ydal Reooros Section Application to TotivnlCity Clerk for Copy of Marriage Record TYPE OF RECt)RD C3E~R£D (Entalr ~~lumber of Copies) Search and Fee a~o.oo Certified Transcri er co t ^ Search and Fee $~o.oo C ifi d C ^ py p p ert e opy per copy A Certified Transaipt is an abstract from the marriage record isbved under the A Certified Capy indudes ap of the items d irdarmation accumng an the original seat of the townlaty derlc. n indudes the names of the oartrading parties, their record of the marriage. residence at the time the fioense was isatfed, date and place d manage as weY as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage aid csrtain other detailed irdamation may be required such as: passports, veteran's benefds , A Certified Transaipt may be used as proof thffi a manage occurred. court prooee~ngs, err settlement of an estate. i3ride1t3coomlSpouse Name (as recorded on marriage license): Date of Birth: ~~av, ~ ~ ~Q y~ s fe-epeat `e deogrfege~ ~" - 2 2 ~ ~ 2 . t„e eirwN.e. If Previousty Married, State Name Used at that Time: Residence (at time of marriage): F.,f rrasr t„r ef.Ao &idelGroosztts~o~se Name (as recorded on marriage license): Date of Birth: y~ /C acv ~ ~~ ~ 0 `2~E~ ~ (ereleetBereerrrigy r~.er rrd+. wr elrr w.r. - 2 Z - ~ 2. If Previously Martied, State Name Used at that Time: Residence (at time of marriage): ref ~ loaf aw. 'iMatrriags Inforrrtat'on Place Where Marriage License Was Issued: Place Where Marriage Was Perforated: Marriage Certificate Na.: Local Registration No.: G(/a' yt eY 5 ~ ~ ~ LUG/~~J ~`~ e r S ~ ~ ~~ 11fb"'q- plooo.ro/ ~f t1 ~ Ter Teee/eo U ~r Purpose for which record is required: Date of Marriage or Period Covered by Search: • Yniedma r graft leer In what capacity are you acting?: What is your relationship to person whose record is requred? ~~~~~ (If self, stela "SELF.) I I S..au for ~I A~w~t l~/ad/~ If attorney, give name and relationship of your client to person whose record is required: Signature of plicaM_ -- --- Date: A icar~'s Phone Number. Name o ApplicanC- ~" Please print name and address where record is to be sent: ~~a.v,~p ~~yes ~at/~~0 eS Address of Applicarrtt / 1~ !3 /2o u~ ~ IZ d ^ ~ o h ~ ` ~ ~ ~ ~ s ~r lf/r~ ~ e r a S stet. zra ~ sue. ~P vvn-~w i rq i q rape ~ m z NEW,YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk for Copv of Marriage Record V Ilcfl 1lCGV1 ua vc~uVi r .. ,.~:~...:. .. :: .:...n..:......... /.-:: -: v......,, }::. y'-vv: ~. x. ~...~ ... yv..., .. ;....x ~ ~ .::: ::::: ter:: •.?wr •..• -:.:iii;:..v:: i.. ,.......:. 4... ~ .«: N~r•:v......:%A:': `}ti:~ii:%iii:ii~: .. i~. .. .. .. +~ ...ry r:. ... ..... {+i + 5 j Search and Fee $10.00 Search and Fee $10.04 Certified Co ~ Certification er copy py per coPY A Certification, an abstract from the marriag record. issued A Certified Transcript includes all of the items of information under the sea{ of the Health Department, includes the names of occurring on the original record of the marriage. the contracting parries, 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 parentage and certain other detailed information may be groom. required such as: passports, veteran's benefits, court A Certificatian may be used as proof that a marriage occurred. proceedings, or settlement of an estate. :.......I':4 :~:.: :.: ro. .~. i., v... ... h... ..... .,. .. .. .. • .. .. ..~ ~ ~ ` ..i .. .n .i eS~.n.....~ ..... ..~ ..... :... ... . . . .T.. ......... .... .1..~. . . :::;:. ~.y.:rs~t:J.•• M: i'~~i l -5.v\\:`:.; ;:::~:.~::.:v.::~;n: ~ ny~.;.}::t;• e..::1.• ;::•o.......a...~~,,.,~ .:... .. }.. •:.:. ...:... PLEASE PRINT OR TYPE Name (First} {Middle} (Last) Name (First} {Middle} {Last} of Groom ~ ~ ~ ~. of - ride-~ . _'~ Groom's Age Bride's Age e Date of ~~~ ~ 5 8 ar Date of - Birth ~ t ~ S Residence {County} (State} nty) (State} u Residence (Co K w ~ l ide B .~ l3~ Groom r Date of Marriage I# Bride Previously or Period Covered ~ Q ~ ~ ~ 2 Married, State Name t Ti d Th . I by Search a me Use at Place Where Place Where Ucense Was Marriage Was L " issued ! Performed .. .. ,.., ..............~ .............:.........,. ...~..,.. ~...~,..., ...... ~ ,.....,...........,,5.:::..r:::::::.....:.::::,.....,...:::.;; n..w... n..:-.i~: +.v.v::.....,, : ..............\.~. .; .;y. ~....... ~~. n......,, •. »~:.e::::: .....:.{~.\•}?':i>:5.; ::::..: •:::....,...:::.... ~.~.: Y~::: S%:~ ~ :tip\:•::.v::::.v::i,;.}::i•: i:;::vii<i5:::ii:~::.???:~iT :.. '::::?..::: n,. .,......... ....... .. ..... ...... :{.v-0;: .:v;:;::..:: :..:.. n ,; .....: ..........:::. :.:. ...:•; ::.ne,.:ry. i'4::;:ry. ~..,n. :.: :::::.:~~.:..:.: ii::.iii :~' .: \.~. .:F.. For what purpose is information required? What is your relationship to person whose record is requested? `_,,,, ~~ ,,r ~\ _ ~T i~'rl'~ ~1~C21R~~ ~~'~~ If self, state"self." _ !n what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is required. ~~~~ .............. ...... n.:.:.. ~........................................ ........................... « ........ F.. .5. ~ ..... ................. .............. ...~. ........... .. ...........................: .1............................................... .,.iv..::. ............. t ............ ........... ..... r........ ,.~ :v:.: ~: v:.~ ....,..:. ,: ,....,. ..., :;,; 5t .....:... ~.~:: ,~.~:.. ~ -. ..... }~. ~..:: ~: . ~. ~:: ...... .:. ... i... ev..v. ~ .... i :•:~v. vv~v •r... ~....................::::: 5-i%:-; •:;: i::::.w: x; ..,.....,... ..........................:............... .v::::._ .... :.. . ........ ..:.... ...: r Signature of Applicant ~ Date dress of Applicant Please print name and address where record is to be sent. ~ u ~ ~~~~ d~ . ~ ~ _ u ~~ M ~ ~~ ~ e1~~ F11~ ~~ ~ ~,1~~-} l~ 'v~t~~i ~r ~.l ~1~. ~1~ . DOH-301 (3/93) 1 n ~G !~'F- ~0~(' I~O~I 1, ~~ ,,,, ,. J Ai. L ... SIDE} NY PUB i 1~ ~~~ ^O (a ,~, .`~: Notary Public -State of Florida oc •' : • My Comm. Expires Nov 19, 2f113 "~~'~~° ;; ~~,, Bonded Through National Notary Aiao. NEW YORK STATE DEPARTMENT OF HEALTH Yrtat Records Sedian Application to Town/City Clerk for Copy of Marriage Record TYPE OF;RECORD L~E~FtEf~ (Ent~lir ~ilumber of Copies) Search and Fee $10.00 Certrfied Transcri t ^ er co Search and Fee $10.00 ~ ~ p py p Certified Copy per c ~y A Certified Transcript is an abstrad from the manage retard issued under the A Certified Copy includes all d the items d irdarmation occumng on the ariginat seal d the townldty deck. It ardudes the names d the oontrading parties, their retard d the maniage. residence at the time the license was sued, date and place d marriage as well as date and place d birth d the bride and Boom. A Certified Copy may be needed where prod d parentage and certain other A Certified Transcript may be used as prod titffi a maniage occurred. detailed iMarmatian may be required such as: passporCs, veteran's benefits , court prooeedmgs, or settlement d an estate. $~de~sr~ Name (as recorded on marriage license): Date of Birth: ~. ~ ~tr*. la-~a ~~ If Previously Maned, State Name Used at that Time: Residence (at time of maniage): . ^^ `` &idelGrootrt{~pouse Name (as recorded on marriage license): Date of Birth: j t ~ ~ ,{,~~~ , ~ ~ (o..~.ats~..~r~Dy If Previously Married, State Name Used at that Time: Residence (at time of marriage): F..t rdw t..r sea. Marriage Infcurrtat~n P lac e Where Marriage License Was Issued: Place W e h re M rriage Was Perfomled: Marriage Cer tif icate No.: Local Registration No.: t c ~ ` a ~ - ~~ / ~ . Purpose for which record is required: Date of Marriage or Period Covered by Search: What is our relatio nshi to er f d i i d? Inwhat capacity are you acting?: y p p son Mr rose retar s requ re ~~~~~ (If self, state'SELF'.) c ~ \~ c~ SMrimn br (~>~P~~ IMIdA/~ryJ If attorney, give name and relationship of your client to person whose record is negttired: ig atu of Applicant D ate: Applicart t"s hone Number. nn f r ~ , p ~-~ Name of Applicant: Please print name and address where record is to be sent: ~~~ ~~~ Address of Applicant: l~(~c~i~', ~ 4~e,~t~~ ~a ~ . cJ ~ ~~ .~ ~' State ZIP Aty S~ ZIP VVllwl ~Y/11~ rG~O 1 YI G NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Yrtef Records Section TYPE~'OF RECORD D~~fRE ~ (Enteti Number at Copies) Search and Fee $~ o.oo Search and Fee $~ o.oo Certified Transcript per copy Certfied Copy ^ per copy A Certified Transcript is an abstract from the marriage record issued wrda the A Certified Capy indudes all d the items d infomration occuning an the original seal d the townlaty deck. It indudes the names d the contracting parties, their record d the marriage. residence at the time the license was issued, date and place of manage as well as date and place d birth d the bride and geom. A Certified Copy may be needed where prod d paentage and certain other detailed infannatien may be requred such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage occurred. court praoeedrngs, ar settlement d an estate. ....... i3ridelGno~omlSpoase Name (as recorded on marriage license): Date of Birth: ~3r~i,-~ ~b~' Sip eVcS (or sys at ties d w.riryrJ o I -2~ - ~' 6 ,~ ~ tom. ~,~.,, If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~sr tarids. Var ~ sN. 'BeidelGrtaomlSpouse Name (as recorded on marriage license): Date of Birth: ii l S ~ (aaysaffisso/rrig~ 8 ~ arc. I~~ra. f~~~d I 7 q-Z ~- ~,r r:..r ~ treat. If Previously Married, State Name Used at that Time: Residence (at time of marriage): r•..e sriadr. e,.e error __ ._ _ _.. Marriage lntarmation > Place Where Marriage License Was Iss u ed : ere Marr ia Place Wh ge Wa s Perfomred: Marriage Certificate No.: Local Registration No.: '~ ~, i ~ r town c~ G Ih L/f IJJI~~7 i u r t ~8W/l OY ~Ui~{h1~C~J~~ ~J,~Gij v ~~ ~~ rs.e.. ro.e a Purpose for which record is required: Date of Marriage or Period i Covered by Search: ~° ~~ /o r3 2~tZ In what capacity are you acting?: What is your relationship to person whose record is required? ~~ ~~ (If self, state "SELF'.) ~ ~~ S¢I- If attorney, give name and relationship of your client to person whose record is required: ignature pplicant ate: Applicarrt"s hone Number. ~ /~ IO-14-12 q!~- ~Sy~ i"1a`~ Name of Applicant: Please print name and address where record is to be sent: r Address of Applicant: i~ SJsti~ Lti~ ~a~Gti~ec~~~ ~ NY 12bv3 City State ZIP City Stets ZIP DDH~301 18/111 Page t of 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) * 1881. to present (530.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certification Unit P.O. Box 2602 . Albany, NY 12220-2602 www.health.ny.gov/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtyderfc nycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH3ot (8111} Pie 2 of 2 -J 11.:1 -~ I~RIVER.,~,~NSE IQ: 593 X68 tRi .ClA$S R ~J# w 01-2T ~ ~~ ~:; ,g __ ~ EYES: _ E: H ~ ~. j~ R: ; NINE '. 7.µH7 -, ISSUEEl:01~3-11 EXPIRES:Ot-27-15 p~iy~~z + NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk for Copy of Marriage Record vital Reoads Section TYPE OF REC4Rfl DE~RED (Er>fteRr °f+lt~mber of Copies) Search and Fee $t o.oo Certrfied Transcri er co t ^ Search and Fee $t 0.00 ~ p p py Certfied Copy per c ~y A Certified Transnipt is an abstract Iran the marriage record issued under the A Certified Capy includes ad d the items d information occumng on the aignat seal dthe town/dty deck. It mdudes the names d the oontraaing parties, that record d the marriage. residence ffi the time the licenae was issued, date and place d manage as weN as date and plea: d birth d the bride and groan. A Certified Copy may be needed where prod d parentage and extern other A Certified Transaipt may be used as proof thffi a marriage occurred. detailed irdorrnaticn may be required such as: passports, veteran's benefits , court prooeerings, a settlement d an estate. i3ridel(3roomlSpouse Name (as recorded on marriage license): Date of Birth: i ~ ~. ~ ~ Ld rQn ~N... ~ a~ i~i~5 If Previously Married, State Name Used at that Time: Resid~n~ce (at time o marriage : _ XQ l t '~ ~ ~ ~U o LX 1 WQ~, rs~c ~ NC I2s4i, ~ ate. &idelGroomtSpottse ' Name (as recorded on marriage license): Date of Birth: (a..y.,er~.ar~wy m ~. S ~ ~ Lou~hrQr~ ~~. o a5 iq7~ If Previously Married, State Name Used at that Time: Residence (at time o f martiage): f~ yy ~~ D~~~~ ~ ~ ~, ~ Ll(.C~` 1t°S ~ ~. ~ Marriage <tn#arrt~atian Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: 7aw-~ of ~Va~~- ~~ ~ ° V J ~ ~~d r ~ ~ ~ ~ P~ ~~ ~~"'- R Tarn ar ~h s T~a Purpose for which record is required: Date of Marriage or Period s ~ , L ~ ~ ~ ~ -~ o~na.~ne Ch~~ Covered by Search: ~ ~ ~ 2 Z~ In what capacity are you acting.: What is your relationsh~ to person whose record is reqused? , / ~• i~ (If self, state "SELF'.) S S~aA ra 1~s~.o/igp.ri.~ ~w/dd/~ If attorney, give name and relationship of your client to person whose record is required: Signature of Applicartt Date: Appliaittt's hone Number. Name of A icant: Please print name and address where record is to be sent: Address of Applic nt: ~/ V f'~ .~ .Z J~ (~ ~' Sfare ZIP Cdy Sfata ZIP uvnyu i rw ~ ~ ~ rape i of z ~~~ `~#8~, CLA,S~ ~~ ~ .. .~~~~ r ~~ • r NEW YORK STATE DEPARTMENT OF I~ALTH vital Records Secfion Application to Town/City Clerk for Copy of Marriage Record TYPE OF'f~ECORD DE~RE © ~Erlfter f~lumbsr of C.t~ies) Search and ^ Fee 16to.oo Certrfied Transcri t per spy Search and ^ Fee $io.oo C rtfi d C p e e opy per copy A Certified Transcript is an abstract from the manage record issued under the A Certified Capy includes all d the items d informafion oocruring on the original seal d the townldry clerk. It mdudes the naves d the eartractirrg parties, ttreir record d the manage. residence at the lime the license was issued, date and place d manage as weA as date and place d birth d the pride and groom. A Catified Copy may be needed where prod d paentage and certain other detailed infarrnadien may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a manage occurred. court proceedings, ar settlerrrent d an estate. BridelQ~rol5pcuse Name (as recorded on marriage lice nse): Date of Birth: n ~E,c°il+~h ( 1'r'' ~ ~~ rl? C~ N 2~ ~ ta-.w.e~.or..,~i ~ err ~ ~ a-.wxa^. ~'~3 -~J If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fid 1&da~ lart Coldy af:Ar &idelGroomtSpoctse Name (as recorded on marriage license): Date of Birth: _ If Previously Married, State Name Used at that Time: Residenxe (at time of maniage): ~ urdw t,.r tra. Marriage trtforn-ation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: I ~Ap , rvS -e ~2 D~~l ,ors t~v ~~,i~~fet~Os, l D~f ~~.~rss ""~°"'- ~-.~ Tewl ar Towl M Purpose for which record is required: Date of Marriage or Period r-~ ~~- N~ ~~~ v u w I Covered by Search: IA~ria as x s..os tja.r In what capacity are you acting?: What is your relationship b person v~iwse record is requked? ~~~~~ (If self, stath'SELF'.) D~2S ~ <<= S~ L ~ s..er-r~ ~~~ ~~~~~ If attorney, give name and relationship of your client to person whose record is required: Si o of Applicant Date: Applicant's Phone Number. N e Applicant: Please print name and address where recoM is to be sent: /~ ("'1 J ( ~ VN~ ~ / `t ' J 6 I'Vt ~ N e-~ Address of Applicarrh ~ a rc e~~h~~ ~~, d v k~~e Sim 264 City State ZIP City State ZIP UUM{%11 Rf/11) F''aQa 1 01L Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtyderfr.nyagov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212} 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on fife with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (6111) Page 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to TotltmlCity Clerk for Copy of Marriage Record TYPE di= i~irCORD DE~RE __ © (Enter.Number of CopiQS) Fee S10.0o Search and Search and ~ Fee $t o.oo ^ Certified Transcript Pef SPY Certified Copy per copy A Certified Transaipt is an abstract isam the marriage record issued under the A Certified Copy includes afl d the items d infamtation occumng on the anginal seat d the tawnlcity deck. n mdudes the names d the aontradmg parties, their record d the marriage. residence at the time the license was issued, date and place d marnage as well as date and place d birth d the bride and groom. A Certified Copy may be needed where proof d parentage and certain other detatied irrfomtatian may be required such as: passports, veteran's benefits, A Certified Transaipt may be used as proof tlrat a manage oocu-red. court prooeedxtgs, ar settlarrent d an estate. l3ride!(3roomlSpouse Name (as recorded on marriage license): ~p i ~ Date of Binh: ..ri..~.~ ~-. e'r1 ~m~1 5~~ CG 1~~{~ y ~ 61 a I g ~ ~. ~ ~~. If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~,~-Chi /U`/ ~,t ~ ~ ~ ate. &idelGr<~orrttSipcttse Name (as recorded on marriage license): Date of Birth: s(3 ~ ~ $S ~. ~ eir,tM.» If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~F~he~s /U `/ r~ a>~ r,~r a.~. _. Marriagt} tnfonetation Place Where Martiage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~~,;~, ~~ N ~ ~Q~ ~, y l~~ p~ Team r Teen a Purpose for which record is required: Date of Marriage or Period Covered by Search: Il~i~dena s..oa rn~ q ~ ~ hi h d i d4 l ti t v Wh ~ In what capacity are you acting?: p o person w ose recor s realu e a ons at 1~ re N,,,,,~~~~ (If self, staff "SEEP.) SL' 1 ~ S..d- be le>~w~1 (~/ea/nrrl If attorney, give name and relationship of your client to person whose record is required: Signature d Applicant Date: Applicant's horse Number. to to to ~sy.5 -Ana-~~G~ Name of Applicant: Please print name and address where record is to be sent: `~~/ `J Cl Fl~ ~~ IC i I l I-~0C91~ +=(J ~~f~Y'tc~ l I ~C ~ Address of Applicarttt ./U `( I aS33 Cdy Sa1® ZIP Cdy Sob ZIP DOH~Ot 18111) Pepe t of 2 ..~,lr ~ W Y VKri a 1 tii ~ -n~(~~ j~yCLCu ~\ DRIVER LICENSE ID: 979 342 623 CLAS$ ~ RYAN EMIL1CrIESA F~SHK! ~ Rpa= ~WELf_ ~u~l1(7FI NY 12833 08-06 SEX: F EYES:`~R HT' 8-04 E: NON[: ;: R: NONE ~K ISSUED:O&24-12 FXPIRES.08-02-14 a~cwwus3a NEW YORK STATE DEPARTMENT OF HEALTH Application to Town/City Clerk for Copy of Marriage Record Vital Records Section TYPE OF RECOR© QE~FtE D (Enter N~mt~er of Copies) Search and ^ Fee $~ 0.00 Certified Transcri t per co Search and Fee $t o.oo C rtfi d C ~ p py e e opy per co PY A Certified Transaipt is an abstract from the manage record issued under the A Certified Copy indudes all d the items d infamafion occurring an the orignal seal d the towNdty dark. It indudes ttre names d the oontraclurg pa6es, Char record d the manage. residence at the time the license was issued, date and place d marriage as well as date and place d birth d the bride aid groom. A Certified Copy may be needed where od d pr parentage and certain other detailed irrfamaficn may be required such as: passports, veteran's benefits , A Certified Trarsai m be used as pt ay Prod that a marriage occured. court proceerings, or settlement of an estate. Bride{aroomlSpouse Name (as recorded on marriage license): Date of Birth: (J Q~ a lit; ~h'~ eve -- ~•~..~~..~..~:a., - ~ t y ~ t~ ~ >waa. ~,r arrr u... If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fwar /Iids~ !bt ~ SMr ''8ridel~rootNSpause Name (as recorded on marri ag e license): Date of Birth: // ~~ ,~ ~ 1 I I l ~ f 8~ F:.r ores. ~. ers,N.» If Previously Married, State Name Used at that Time: Residence (at time of manage): '~-tC l~Ls s N `/ r~.r Nrds. ta.r ~. Marriage tn#orrnatc~n P l ace Where Marriage License W a s ued: Iss Place Where Manage Was Performed: Marriage Certificate No.: Local Registration No.: tt ,, ' ~ r ~, ~ Y~CY `S ~1 i S I L/~ ~-)'KS) ~OC-~ghkL~jls~ r ~l~C~l'1LS 5 Rb~e..l fr~-I Tew-a T a Purpose for which record is required: ~ Date of Marriage or Period ~ C~~ ~~~ ~~ S~~ ~ ~ V~ ff ~ 1 ~5<., Covered by Searoh: Ilnri~d on a •I SMafr io~r In what capacity are you acting?: Whet is your relationship to person whose record is requved~ (~/dd~~ (If self, state'SELF'.) s..d- ~ ta.+.a~:gp.~.aP Nw/dd/~I If attorney, give name and relationship of your client to person whose record is required: igna d Applicand Date: AppG s hone Number. O Z N am e of Applicant: Please print name a addre record is to be sent: ~ ( I~C~U L I/1 (~dt ~ Address of Applicant: c ~ ' ~ O 1 1 ~,mLSc>» ~f'~t l ~ O O Curfit~ Corrx.,-s N~ ~2-~b ~' ~.~ s ~ -9,0 F c ~' S'rare ZIP Ciry ~p uun,^~ui rant rape ~ of z ~ r .~ NEW YORK STATE DEPARTMENT OF HEALTH Application to TotlmlCity Clerk for Copy of Marriage Record vital Records section TYPE t]F RECORt7 ~E~RE ~ (Enter ~~i~rnbet• of Cv~i+ss) Search and Fee $~ o.oo Certrfied Transcript per copy Search and ^ Fee $10.00 Certfied Copy per c oPY A Certified Transcript is an abs7act tram the marriage record issued under the seal d the town(aty dark, It includes the names d the corrtradtng parties, their residence ffi the time the licence was issued, date and plane d manage as weN as dffie and place d birth d the bride and groom. A Certified Capy includes aN d the items d information ocauring on the original record d the manage. A Certified Capy may be needed where prod d parentage and Detain other A Certified Transcript may be used as prod thffi a marriage occurred. detailed Arfarmffiian may be rearmed such as: passports, veteran's benefits , court proceedings, ar settlement d an estate. &idel6roart~/Spouse ' t? r1 C( C)I ~ i Ct O O P' ~ 8 Name (as recorded on marriage license): Date of Birth: tor.o.atr..otw.rvyy ~ ~ t,.r e:mw.. If Previously Married, State Name Used at that Time: rxr ~ ~ Residence (at time of ma age): Surre~c ~anQ~ wa p i rr~en -~«1Is , 'Dv-FcG~2ss ~ srt. Bridt#GroomtSpouse S j~ `{ (" i OI'1 bi ~'IS C>~ ~ ~ ~ Name (as recorded on marriage license): Date of Birth: (a+w+r~ a.rrriyy F..r treat t.,r tam ~, If Previously Married, State Name Used at that Time: r~..r rrea. ~r Residence (at time of marriage): `~~ Surf=-~{ LrxYl2. Wappi~c's ~«Ils, t7u+c_hess are. Marriage tnforrnafion Place Where Manage License Was Issued: INa~i~e~~ ~'al~s Place Where Marriage Was Performed: Wa~i~~ rral~s Marriage Certificate No.: A~ Local Registration No.: ~~ Two a Twn a " Purpose for which record is required: ~~~ ~~ ~ ~ I i ~~~ Date of Marriage or Period Covered by Search: rll~rirdoaa s..a~-~ In what capacity are you acting?: whet is yow relationship !n person whose record is requved? (If self, state "SELF.) ~~~~~ ~ stab Ioc (Na+.deAyPw1.4 ~w/dd/~ If attorney, give name and relationship of your client to person whose record is required: Signatu icant Date:1C, 3 (2 AppNcaM's hone Number. S I ~_ ~ v _ c~.~~l 6~ Name of Applicant L6UIrt ICXI(1-'~t Please print name and address where record is to be seM: Address of Applicar>x `~'E ~umPu Lct v~ o ~~ni r~~~ 1 ~ Cify State ZIP Gly Sfeb ZIP uvnvu i rw ~ U rage ~ o~ c Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) * 1881 to present (530.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certrfication Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtydark.nycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212} 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOFI,901 (8111) Page 2 of 2 Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ^ Fee $10.00 I ~~ and ^ Fee $10.00 Certification t~ spy Certified Copy 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. 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. DOH-301 (3/s3) (PLEASE SEE REVERSE SIDE) NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Co of Marria a Record Vitat Records Sedian PY 9 TYPE OF»RECOFID DE~RE b (Enter 1Mumber of Copies) Search and Fee $~o.oo Certified Transcript ^ per copy Search and Fee $~o.oo Certified Co r co PY ^ Pe PY A Certified Transanpt is an abstract from the manage record issued under the seal d the townlaty deck. It indudes the names d the contracting parties, their A Certified Copy indudes all d the items d information ooauring on the anginal record d the marriage. residence at the time the license was issued, date and place d marriage as wed as date and place d bittlr d the txide and groom. A Certified Copy may be needed where proof d parentage and certain alher A Certified Transcript may be used ~ proof that a maniage occurred. detailed information may be required such as: passports, veteran's benefits , court prooeedrngs, ar settlement d an aside. &idelGroom/5potase Name (as recorded on manage license): ' ' ~ ~ Date of Birth: (araysafiwaorwanL aJ l V 1 /v Q t] 1~~ - ~ ~ y ~ F~ ~' a-eh Now. ~ ~ ~ ~ - ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~ '~c-~ieS S /Vr Fein ~' ~,r ~ sr~! BridelGr~rnJSpause Name (as recorded on marriage license): Date of Birth: .~.d~.~..~:a,, ~ ~ Q ~ ~ vn ~ ~, P P ~ ~ / Fear tyid~ [nf Bi/i News (p ' ~ ' ~ L If Previously Monied, State Name Used at that Time: Residence (at time of marriage): 1 ~~r~ n~c_ VV1 • ~cv1 ~Q~ lC~ ~-c,~res~ ~ ~ t~ ~ ~ Marriage Inforrttattirtt _::: ,,: Pla ce Where Marriage License Wa s Issued: Place Where Marriage Was Perfom>ed: Marriage Certificate No.: Local Registration No.: ~~ // ~ % W4P~riJCr' 1'" ~v~c/te°55 cc//`` G/a'/o~iLl~~r ~~T~i~Ss ~ws~V ~~1 Town a Tows a Purpose for which record is required: Date of Marriage or Period Covered by Search: rwiaaar a ~°~` `°~ 9 3 In what capacity are you acting?: What is your relationsh~ to person vrFwse record is required? e /,~ - (If setl, state "SEEP.) ~~~~ I ~ Sawrh be la~aw~~i M/aa/~ If attorney, give name and relationship of your client to person whose record is r+eq<tired: Sign of Ap icaM ate: AppGcanYs hone Number. f~~•/z ~ys=y~~~-~~90 Name of Applicant: Please print name and address where record is to be sent: Address of Ap icant: ~b L Cdy a ZIP Cdy Stets ZIP DOH301 (8/11) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to ToWnlCity Clerk for Copy of Marriage Record a"~I Records section TYPE OF RECORD DESII~f >~ 4Enter Number of Codes) Search and Fee $t o.00 Search and Fee $t o.oo Certified Transcript per copy Certfeed Copy ^ per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy indudes all of the items of irrfannation occurring on the arignal seal of the townlaty deck. It indudes the names of the cartracting parties, their record of the marriage. residence at the time the license was issued, date and place of marriage as wep as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other derailed mfarmafian may be regtired such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a manage occurred. court proceedings, ar settlement of an estate. Bridei'f3roa~tlSpat~se Name (as recorded on marriage license): Date of Birth: (aaprartie.otarrfgy ~e If Previousi artied, State Name Used at that Time: Residence (at time.of marriage): i t=oll C' 1 i c tr6ddr C. IJ1f Cglnlp s1~A1 - &idelCsr use Name (as recorded on marriage license): Date of Birth: k-+p.:r trams of uaniry~ r.,e G ~ array. t,.r ~ /1 a~ a.» -- 3 O - 7 ~ If Previous y Married, State Name Used at that Time: Residerx;e (at time of manage): rya ssdw t~ ~ ara. Marriage lr>farmation Place Where Marriage License Was Issued: Place Where Marriage Was Perforated: Marriage Certificate No.: Local Registration No.: A-~l pfd /'' Taws ar /t< Tows w Purpose for whit rec is required: Date of Marriage or Period Covered by Search: 2 i V~ (~ L~ Y"1 sus ~ "T t Z U/ In what capacity are you acting?: What is your n~tionship to person whose retard is requrced9 ~ ~ ~~ (If self, state "SELF'.) s..oa Ioc ~a~ahisypwiat] haw/ddJ)7)ry1 If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date /~ /J Z Applicant's hone Number. Name of Applicant: Please print name and address where recoM is to be sent: Address of Applicarth ~ UP ~~ %~n v; ~ u; 1712 ~ ~i~~~ Y~~/ !V ~ ~ ZS 7~ City State ZIP Cdy Stall ZIP DOH~01 f8it1) Pape 1 of 2 ~` ~ ~ ~ ~ ~~ ~~~ ~~~1 l ~. Of the UnitedStates, -_ inOrderta form amoreperfect Union, establisbJxstice, insure domesticTrangxility, ~ - -_ provide fortbe rommox defence, ~ ___ promote tbegenera! Welfare, axdsecxre ~ ~ tbeBlessin~rs o/Lrberty to oxrselvesand , , _; ~ ~rrlydrtdittyy'flordainandestablicbtbzr y Cnnstilutr''n»fortheG'nitedStareso{-Lnevrs ~ ~ - ~, > ~ F,. ~ p ~~~ ~, 'r;~ .~ _ '~ ------ _ _ SICiNA'FtiRE OP BEARER , ~r~fd PASSEM!ART. ~~' "~t~ PASAPORTE TYpe. TYpe~T ~~ Surname / ~'~, =~`~~ _~- ~~__ RVJJC4F: ;Ap "'~, P. s.6~ !'Y~'7,[ Given Names / Pr~norti5'/ (~iptes ` y1i •`.'~,,., 1 - Y `~.'~f' xr ~- ~SHIA ALOf~y e ~ ;~nality / Nationalitb F.Nacionaiida8~ ' ~ ~ ~ Q ~IITED STA7E~. ~F AI~(ERICA s _ Date of birth / Date de nai6sance I Fl:cha'de nacimiento '_ ~ ~ _:~~1. QJul 1976 '. `. ~ "'~' of birth f Lieu de na~ssance / Luga~de nabimienlo d' 1` ` ~ $ex / Sexel3 ~ : ~- ; a~~VN YORK. U S /~; ,~. . . f Date of issue /Date de d§bvrarice / Fecha~dE expedicibh Authority t AutrnTt~ F~Autondad - rtir~ii'~ ~ ralofl'rtd~~SErpYt~~~tiid~oaduoi4ad U~ ~nnnrtrY~. ` tk +~ depar `ent o~ ~ti~.;~~iX~a~ # Endorsements!'MiintionsSpbcialeslAnotaciones .see ~a~E 2~ ~_: P<USARUSSELL«TYESHIACALOMA««««<«««<< 4490703274USA7607017F18OT217228$76578<517420 3, Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Yeaz of Marriage * 1881 to present ($10.00 per copy) * 1881. to present ($30.00 per copy) If a state issued copy is required or you aze not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtydsMlr.nycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kingsj Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on fife with the New York State Department of Health) PLEASE NOTE' Records of marriages in azeas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOFI,901 (8111) Page 2 of 2 so a' G.e~ a7~e '~` ~, ~ ~ 3 30/ ~~ ~~~ ~ ~~ ~. G3CC~C~OM[~D SEP 21 2012 TOWN OF WgppjNGER TOWN CLERK T t~ 'tc ~~- ~~,. t0 DER -o E~: ~ ~.,.~ Q ~A~ ~~ o ff, ~j'~°v~' ~RTH L EE,1( ~ sT{~ S'J;1CR~ ?~0 A.i~D t3U Ciao ED BEFORE E f;GTI~Y E'145~lC S,FTt. Cs," "~ti'" 'RI f~/Y Cfl+~,9~lli~~i'?PJ ~ :~dF;E~: CGtJNTY GF KRISTEN E. AR HE Notary Publ~ -Notary Seal State of NAssourl Commissioned for St. Charles Cou My Commission Expires: Ocrober 14, 20 4 Commission Number. 10393484 SAX Transmission Number o~F pages including cover sheet ~ , Attention: ~ Company.~..--- phone: •//~~~/- W 1 Fax; .,~~.,., ,,~~ Date: From: Company: Phone: -~ - Comments: ix• ~~, ~~ m pRn~ ~;~ nnns ~ A~A~NT ~ uo~uM~NT s~RV~css Local Fax per page ~ ~ x-~o Long Distance Fax per page - ~ 2.00 2846 Veterans Memorial Parkway Saint Charles, M~ fi33f33 (636) 949 X284 {636) 949 8295 Fax impress0388~afficemax.com nnnrirrn•wwrnw.~.w•nrrw1asmwwwnw~www..+.rr.w..~ww~eww~.a+Mwwu+w~.nwyrywr~..~++~+'...~+~ww+w.www+rn~wrr.w+....-y~.w~w+.nwwrwiwnroyr~.«..'r*iw~.nw~n.r~rwnwa~r+~••-nar•nrw~•v~,•~awiwn,w~,rw . , ..~ rr .r. .n r ~~. ~....~... ...rw..+~...+~ A' ~ ~ 1 C~"'~ ,Q~ l7~~%S~']~ r d ~ i NEW YORK STATE DEPARTMENT OF HEALTH Vitcl Reosrds Segion AppUcation to TotivnlCity Clerk for Copy of Marriage Record _ __ TYPE OFl#~EC4RD Q~~iRE a ~Ent~r dumber of Copiet;) Search and Fee $10.00 Search and Fee $t o.oo Certified Transcript per copy Certified Copy ~ per copy A Certified Transaipt is an af>stract from the marriage record issued under the A Certified Copy includes afl d the items d information occumng on the angincl seal d the townldty deck. It includes the names d the oartracting parties, their record d the marriage. residence at the time the Goense was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Copy may be needed where proof d parentage and certain other detatied irrfarmation may be rearmed such as: passports, veteran's benefits , A Certified Transaipt may be used as proof that a marriage ocat-red. court prooeerings, ar settlement d an estate. SridelGroomlSpouse Name (as recorded on marriage license): Date of Birth: .Q l~ S~t~~~ ~ ,~ A~~ ~..a.~~.~.~., ~ >~ e S ~ err-w.» oy oa ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~, r , / ~afc ~ t4'f ~V I Fisf tltid~a Isu C~'MY libAr BCIde~GrOOEif~pOtiSB Name (as recorded on marriage license): Date of Birth: O ~ oa ~~ 5 r-..r rwsi. t,.r aran ry.» If Previously Marred, State Name Used at that Time: Residence (at time of manage): ~~,~ctics5 /vY r~ tr«rdw tape craw Marriage lnf.Or'/t18~lat!'1 Place Where Maniage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~lec ~ ~~ W ~ail~~ ~ ~ra..~f p~ . Tawr x ~ ~..~« Purpose for which record is required: /j ~+(~~ .,~, ,~ ~ ~'~ ~ ~~ CI11~c~.~~G'V> Date of Marriage or Period Covered by Search: In what capacity are you acting?: What is your relatiorrship to person whose record is requked7 ~,,,~~~~ (If self, staff "SELF'.) srd- ac ~fs~puia~ (ww/Ad/~) If attorney, give name and relationship of your client to pennon whose record is required: Signature d pliant Date: Applicant's Phone Number. Nam f Applicant: Please print name and addres wh~ cord is to be `` ~Ja-M~5 Sf ~ac~ ~ ,~ Address of Applicarttt '~' 2 ~ , lL ' e c- ,, < ~ ! ~ ~ `~ ~ City Slate ZIP City SfaM ZIP DOH~Ot (8111) Page t o} 2 NEW YORK STATE DEPARTMENT OF HEALTH vrtd Records section AppUcation to Town~City Clerk for Copy of Marriage Record TYPE OF F~ECORD<l~E~1F~ED (Enter Number of C:apies) Search and Fee 1610.00 Certified Transcri er co t Search and ^ Fee $10.00 C p p py ertified Copy per copy A Certified Transaipt is an atrs7act from the marriage record issued under the A Certified Copy includes all d the items d irdarrnation occumng on the original seal dthe torm/dty deck. It includes the names d the cantrading parties, their record d the marriage. residence at the 6me the license was issued, date and place d marriage as well as date and place d birth d the bride and Boom. A Certified Copy may be needed where prod d parentage and certain other defafied itrrfamaticn may be required such as: pagsparts, veteran's benefits , A Certified Transaipt may be used as prod that a marriage ocaured proceedings, ar settlement d an estate. 8ride1t3room/Spouse Name (as recorded on marriage license): Date of Birth: foray.. tts.o>~/ ~ ~Gtr~C~ taas~. fr~~~ G- ~ ~on-~ne,2 arr~t+r.^. ` ~! 13 (D5 If Previously Married, State Name Used at that Time: Residence (at time of marriage): Frsf ~~ !a!f Coaa1Y SIGN &idtalGroortlitS~ouae Name (as recorded on marriage license): Date of Birth: laaw tia. of a~.ri.~y F.,r• MAC Y;,,~, ~ ,n-~-~iY-2'Z.. ~~. ~ ~5 ~to If Previously Married, State Name Used at that Time: Residence (at time of ma 'age): r~..r tardy. v.r aw. Marriage tnforrnatiot~ Place Where Martiage License W as Issued: Place Where Marriage Was P e rf or m ed : Marriage Certificate No.: Local Registration No.: r ~ ~j)~fl~-+I@ C~ ~~`3~~ '~ ~ n ~ ~ ~ f U ~ ~ ~cl .J~ ~'~ ~~ '"'~.'~T ACId~ Irr~ewr/ ~~/ rewr a ioam er Purpose for which record i s required: Date of Marriage or Period I ~t ~ C'l ~-~ e- ~-~ ~ I w~ir.N.ry Search: o ~~ In what capacity are you acting?: what is yore re~tionship to person whose record is requred? ~!~!~ (If self, state'SELF'.) s..d- be ~a~pwdw4 (wwldd/Pt+179 If attorney, give name and relationship of your client to person whose record is required: ignature of Applicant Date: Appli s hone Number. Name of Applicant: Please print name and address where record is to be sent: Address of Applicar>x ~Y State ZIP Cdy Stag ZIP uvnvui ~o/i iI rape ~ or c --r- __ ~~ X61 =~- NEW YORK STATE DEPARTMENT OF HEALTH Nrtal Records Section Application to Town/City Clerk for Copy of Marriage Record TYPE ~~ RECURfl<C~E~RE b (Ent®r Number of Copies) Search and Fce at o.00 Search and Fee $~ o.oo Certified Transcript per copy Certified Copy ^ per copy A Certified Transcript is an abstract from the manage record isslled under the A Certified Capy indudes all of the items of information ocarning on the original seal of the townlcity dark. It indudes the names of the oorttracting parties, Char record of the marriage. residence ffi the time the license was issued, dffie and place of marriage as well as date and place of birth of the bride and Boom. A Certified Copy may be needed where proof of parentage and certain other detailed irrfamation may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof thffi a marriage occurred. covet prooserings, or settlement of an estate. Bride~t3roorts/5potrse Name (as recorded on marriage license): Date of Birth: ~-.o.,r a.. ~o.aa, D Na mrn ~~ 5~i ~' R ~ ~ 1 ~ ~o . o ~ ~1 q ~S ~. ~ ~,w., If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~~~. ~~7~Hs ti.r ~. ~ : &idelGrQOtzitSpouse Name (as recorded on martiage liven ): L. ~ ~ ~~ ~ 091 ~s by Date of Birth: k++D+af 6M Narrii~y~1 If Previously Married, State Name Used at that Time: Residence (at time of manage): 'Mat~riage trtfor~atiurt '> Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: !~yar,0~in~ ~,es" ~~11~ ~j/~1'~;~r9 ~~s~~il~s ~~ p~ /~ ~ ~ ~ Tewr r r~ Purpose for which record is required: Date of Marriage or Period Sa ,n ~~ 1 C ~ Covered by Search: Ynirdena ,Y .. 8rdlr love: In what capacity are you acting?: What is your relationship to person whose record is requireed? ~Ide~l~ (If self, sta~'SELF'.) s..d-~ If attorney, give name and relationship of your client to pen~ort whose record is required: ignature iyant Date: Appli s hone Number. ©~ 3 ~~ Name of Applicant: Please print na a and address where record is to be sent: Address of Applicant: City Slate ZIP Cdy SAN ZIP DOH~p1 (8111) Pepe 1 of 2 NEW YORK STATE DEPARTMENT OF HF.At.TH Vitt Records Sedian Application to Town/City Clerk for Copy of Marriage Record TYPE QF R~C4R© ©E'~REb fAEnt~r ~+lumber ot'Copies) Search and Fee t610.oo Search and Fee $10.00 Certified Transcript per copy Certified Copy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy indudes aA d the items of i anon ooarmng on the original seal of the torm/dty deck. It indudes the names of the oartrading parties, their record of the marriage. residence at the time the license was issued, date and place d manage as weN as date and place of birth of the bride aid groom. A Certified Copy may be needed where proof of parentage and certain otirer detailtired irrfarmatian may be requrced such as: passports, veteran's benefits , A Certified Transaipt may be used as proof that a manage accu-red. court prooeerfmgs, or settlanent d an estate. BridelGroomlSpoure Name (as recorded on marriage license): Date of Birth: fo-aa,rr..ot..rryf If Previously Married, State Name Used at that Time: Residence (at time of marriage): Find IliJdi !aM CouMr S1rN BridelCrootNS'po~se '' Name (as recorded on marriage license): Date of Birth: F.at ~ v YiASr .S c,~ 1..r / , ~ Vl V~I "-^- ~ errn rr~. V ~ C,Q~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): Marriage lnforrttati+on Place Where Marriage License Was Issued: Place Where Marriage Was Perforated: Marriage Certificate No.: Local Registration No.: Ake R~ r..aa rowrrr V~~`c:L ~ ~' Purpose for which record is required: Date of Marriage or Period Covered by Search: w~.a«r.. sroer iaar In what capacity are you acting?: What is your relationship to person whose recall is required? ~~~~~ (If self, state "SELF'.) ~ l v~-. ~~ If attorney, give name and relationship of your client to person whose record is required: ig ttirr~nf ppiio nt Date: Applicant's hone Number. gl~~~ ~~~ 5i~. ~3~~ Name of Applicant: Please print name and address where record is to be sent: Address of Applr ca ! \ ~~ 1~~~ C~. ~~ ~ c~~p 1-~.l S ~.-~( 12.- ~~ ~' State ZIP nnu en..eu.~ rL__ . Gh' Stah ZIP ...... ..... .... ... ...yo . ,.. OF-14.f:1 BQ'~S: Q2-S7-47 ~A NEW YORK STATE DEPARTMENT OF HEALTH vial Records section Application to Town/City Clerk for Copy of iarriage Record TYPE OF REG4Rfl 'L~E~RE © {Enter'Number of Cc3pies) Search and Fee t6t o.oo Certified Transcript per copy Search and Fee $10.00 Certfied Copy ^ per copy A Certified Transcript is an abstract iron the marriage record issued under the seal d the tawnlc~ty clerk. It includes the names d the contracting parties, their residence ffi the time the license was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Copy irrdudes all d the items d information occurring on the original record d the marriage. A Certified Copy may be needed where prod d parentage and certain other A Certified Transaipt may be used as proof thffi a marriage occurred. detailed krfarmaticn may be required such as: passports, veteran's benefits , court prooeed'mgs, ar settlement d an estate. BridelGroorhl5pous® Name (as recorded on marriage license): ~~ c ~ ~` ~ G ~/NaM Date of Birth: (orawat fem. ol..rt~y~l ~ /~ ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fid 16d~r !at Camry S6M &dellroorrt/~ou~se Name (as recorded on marriage license): Date of Birth: F U ~~~~~ ~ W ~ ~ InG (T~ D ~ ~B~N~ l 0 If Previously Monied, State Name Used at t Time: Residence (at time of marriage): F..t rraa. t,.r co~rr a>.r. __ Marriage In#orntstion Place Where Marriage License Was I I `~ l/~ ~~i ~ 7awi ar ~ Place Where Marriage Was Performed: ~a wt~ ^ Tew~ K Marriage Certificate No.: A~1 Local Registration No.: ~- Purpose for which record is required: n n' n Date of Marriage or Period Covered by Search: s,.or~ ra.r ! q In what capacity are you acting.: What ~ yow relationsh~ b person whose record is requkedT (If self, state "SELF'.) t..,i ~~ ~~ If attorney, give name and relationship of your client to person whose record is required: Signature of Applica ate: Applicant's Phone Number. /~ ~ ~1° l')/ f'~ ) ~ S~ 1 b ~~' S~ Name o nt:, C ~ Please print name and address where record is to be sent: Address of Applicant: ~1' State ZIP City State ZIP vvnw ~ rw p i t rape ~ or c NEW YORK STATE DEPARTMENT OF HEALTH 1!dffi Records Section Application to ToumlCity Clerk for Copy of Marriage Record TYPE OF'RECQRD DE~tl~E © ~ERter fVumbt3r of:Codes) Search and Fee ~~ o.oo Search and Fee $t o.oo ^ Certified Transcript per copy ^ Certified Copy per copy A Certified Transcript is an abstract from the marriage recall issued under the A CerEfied Copy includes aU of the items of information occuning on the original seal of the townlaty deck. It mdudes the names of the oorrtrading parties, their record of the marriage. residence ffi the time the license was issued, dffie and place d marriage as well as date and place of birth of the bride and groan. A Certified Copy may be needed where proof of parentage and certain otlrer detailed irrformatiar may be regrrired such as: passports, veteran's benefits , A Certified Transcript may be used as proof thffi a manage occurred. court prooaetings, a settlement of an estate. i3ridelGra~omlSpot~se Name (a~s re)corded on marriage license): .~CG~ - ~ Date of Birth: (ap~~t6aef~wrRDy ~ --I~ /!r" ~/~,.J7 Q, C~J 9 - a o - 5~ t~r,r ~. ~ a~ ~.,. If Previously Marred, State Name Used at that Time: Residence (at time of marriage): Fwsf IRdd~ laif Coanlr SYH '' &itielCrQOmlS~cuse Name (as recorded on marriage license): Date of Birth: `` ~~ ~ tyres. t..r eren N.w. If Previously Married, State Name Used at that Time: Residence (at time of manage): Marrisge;tnformation Place Where Marriage License Was Issued: Place Where Manage Was Performed: Marriage Certificate No.: Local Registration No.: tiUn~ii~s~w-!f ~,,~-~,~5~ w~D~"~~!(s ~.rF~ss ~-~..a air Tewi ar Twn a CesM Purpose for which record is required: Date of Marriage or Period Covered by Search: ~ `~ ~~`''"~-~- ~ ~ o ~ - 1 S -a ~Z In what capacity are you acting?: What is yore relationsh~ to person whose record is required? t~Idy~t+rin/ (If self, state "SELF".) 8rrd- ~ le~n«~ I~/dd/m71 If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: A~rlicant's hone Number. Name of Applicant: Please print name and address where record is to be sent: ~ ~w~ `~`~a~ ~©2rn~a Address of Applicarrt 3~~~ `~~~\~~ ~d ~~r.,~-~.Q~~-C~ ~l ~y ~ a~~ 2 City State ZIP City SfeM ZIP DOH~Ot (8It1) Pape 1012 0811312012 23:45 8452325744 POUGHKEEPSIE GROUP PAGE 01101 a s i .~; .~, ' ~y , `~,f ' Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ~ Fee $10.00 Certfication per cePY 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 yell as date and place of birth of the bride and groom. A Certification may be used as proof that a marriage occurred. Search and ^ Fee $10.00 Certified Copy per cePY A Certified Trar~cript 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 setttsemment of an estate. PLEASE PRINT OR TYPE " Name (First) (Middle) (Last) Name (First) (Middle) (Last) of Groom ~ r T ~ ' /~,-~ ~ V ` \ (^SG~~ of f ~ Bride ~Gr~ / ~ ~V> c;~' Groom's Age Bride's Age or Date of Birth ~ ~ l (,~ ~ S S~ or Date of ~ g. Birth , ~1 Residence (County) of (State) Residence ~ (Co ) (State) ~ ~L Groom ~_ ~ ~~' S ~ ~ - _>..~ -~.~5 Bride Date of Marriage If Bride Previously or Period Covered Married, State Name ~-' b Search O 2 ~~ c1 ~ Used at That Time Place Where ~ Place Where . ~cense Wag ~~~~~ ~O ~ ,.~. Pertorn~iedWffi ~v ~.~ ~ ~~ N . For what purpose is information required? What is your relationship to person whose record is requested? ~ : ~ ~ `- ~ 1 If self, state 'self.' ~ ~ l Ca,. ~ v \P ~~-~ ~ ~ ~~ ~~ s~S~v~ . In what capacity are you acting? If attorney: Name and relationship of your client to persons whose marriage record is1egnired. Signature of A Date Z~ ~L Address of Applicant Please print a and add ess where record is to be sent. ~Cr t` ~ V~1 ~ S d'~-~ c) S O Vhc~- a ~ ~c` ~~ ~ ~ © hh . r-t r Jv~ Z_ S ~. ~ DOH-301 (3/93) ~ c~ r~ ~ ~ S r (PLEASE SEE REVERSE SI E) JUL~ 2 52012 ~ 1 TOWN OF WAPPINGER TOWN CLERK _~ --- ~ ___ ;~ z -~-__ NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Ydal Records Section TYPE OF',RE~OftQ t~ESlRE Q (Entetr N~trnber of Copies) Search and ^ Fee $~ o.oo Certified Transcri t Per co Search and Fee $~ o.oo C rtfi d C ^ p py e e opy per copy A Certified Transcript is an abstract from the marriage record issued under fhe A Certfied Copy indudes aq d the items d information accuning on the original seal d the townlcity deck. It mdudes the names d the corrtrading parties, their record d the marriage. residence ffi the time the license was issued, date and place d nurriage as well as dffie and place d birth d the bride and Boom. A Certified Copy may be needed where prod d parentage and certain other deleted information may be requaed such as: passports, veteran's benefits , A Certfied Transaipt may be used as proof thffi a tarriage occurred. court proceedings, ar settlement d an estate. BridelGroomlSpouse Name (as recorded on marriage license): Date of Birth: (o..p.,r `. ot..rrreef ~. ~ e~N.~. 3 ~ ~ q If Previously Married, State Name Used at that Time: Residence (at time of marriage): Gl ~Z ' ~ r~ asae. t„r '&ide/GroomlSpeilse Name (as recorded on marriage license): Date of Birth: foreyeafie~orwrrieyy . F.r r ~ ~ /t~ rrasi. ("i~Cc, ta.r l l c~ ~- area w.» `~~ / g' If Previously Marred, State Name Used at that Time: Re idence (at time of marriage} - y ~~ rx~ If~dae tat ~ Marriage<~nfarretatot~ Place Where Marriage ~~~ Was Issued: Place Where Marriage Was Performed: ~am 'age Certificate~No.: egistretion~No.: ~ rover « ~ 7ee~r « - Purpose for which record is required: ~ Date of Marriage or Period w Covered by Searoh: wrled OR « ~' a.ar rear ~y~~ ~~ ~0/2 t i l ti hi t h i j In what capacity are you acting?: s yore re ons p a o person w ose record s required? ~~~~~ (If self, state "SELF'.) se.eu~ ~~ f-wfa9 New/ddl)ry)ry) If attorney, give name and relationship of your client to person whose record is i 'gnature d Applicant Date: A ~cattt's hone Number. T me of Applicant: PI ase pri me and address where record is to be sent: Addre of Appli nt: ~~ ~~ C /Z ~d ~ ~~G , City State ZIP StaN ZIP uvnvui w~ii~ repo i viz WAl~rltvvGr• TOWN 0 TOWN CLERK Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and Search and Certfication ^ Fee $10.00 Certified SPY ~ Fee $10.00 Per copy Per coPY A Certification, an abstract from the marriage record issued under the seal of the Health Departrnent, includes the names of the contracting parties, their residence at the 6me the licerwe 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 includes all of the items of information occurring on the original record of the marriage. A Certfied Transcript may be needed where proof of parentage and certain other detailed inbrrnation may be required such as: passports, veteran's benefits. court proceedings, or setlleement of an estate. PLEASE PRINT OR TYPE Name (Brat) (Middle) (Last) Name (First) (Middle) (Last) v,~e~ ~ ~r1(S"~~ ~~ DG G l ~~ p '1``-` ~0 ~ I ~(; ~ ~~~z~~ ~Q B . oom o . - ide Groom's Age or Date of f ( ~ ~ ~ 7 ~ Bride's Age or Date of / f y j / l ~ Birth Birth Residence (County) (State) Residence (County) (Stab) Groom ~ u `~ C~Q S S `~ 6 ide D ~- C~>~.s S N Date of Marriage or Period Covered ~ i 3' (2 If Bride Previously Married. State Name I b Search I Used at That Time Place Where ~ ~~n was v~c~ ~ ~ ~ ~c~e ~ ~' ~ Place Where N ~ ~ So v~ e ~ s Is ~ , ~ For what purpose is information required? W h a t is yax rel ationship to person whose reoord ~ requested? V \ V ~ ~ Y ~ ,~ l ~. c~.y~uR- S In what capacity are you acting? If atlomey: Name and relationship of your client b persons whose marriage record is required. Signature of Applicant _Z~~~% Date 7 2 c~ ~ ( Z Address of Applicant ~~ Please print name end address where record is b be sent. ~ ~(o ~l. t~~~ , MQ~o~ Lc~(( Pa~g~~~~~ ~~ o ~ zc~ 3 ~, ~~ ,~ . fl~~ ~ Po vq -~1~-~z ~p5~. l~~ ~ Z~o~ DOH-30t 13/93) (PLEASE SEE REVERSE SIDE) .--- -r ..~ .~,~.. _.- _,~.~___ ___-.. _ _._ ~ ,_ ...ATE.-~....~URK STATF~-- -- # ~ - ~, r~~, ,; i5 Z ~ t `fit-. • i, ~~14 tl 'x ti~ ~ ~~ R:- 1~: ~1~6Y~OY i1-11-t2Y cfir+~c+ ~` ..r" -----~ Town of Wappinger 20 Middlebush Rd Wappingers Falls, NY 12590 ***RECEIPT*** Date: 07/31 /12 Transaction(s): Receipt: 51360 Reference .Subtotal 2 2 Cert. Copies -Marriage 51360 $20.00 Check: 3056 Total Paid: $20.00 Name: West, Melody Elizabeth 86A Daley Road Poughkeepsie, NY 12603 Clerk ID: JF Internal ID: 51360 NEYJ YORK STATE DEPARTMENT OF HEALTH vital Records Section Application to TotilmlCity Clerk for Copy of INarriage Record TYPE OF RECORD ~ESfRED (Enter Numberof Ca~i+~s) Search and Fee t610.oo Search and Fee $~ o.oo Certified Transcript per copy Certified Copy `~' per copy A Certified Transaipt is an abstract from the maniage record issued under the A Certified Copy indudes all of the items of information ooatmng an the original seal of the townldty dark. It indudes the names of the contracting pasties, their record of the marriage. residence at the time the lieenae was issued, date and place d marriage as web as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other detailed irrformatian may be rertuaed such as: passports, w+teran's benefits, A Certified Transaipt may be used as proof that a manage occurred. oorat proceedings, err settlement of an estate. Bride1(3ro~oml5pouse Name (as recorded on marriage license): Date of Birth: fa aw err r>^. et..~ty. f tit r t,.t ~.~' aratr.~. 12 I'1 If Previously Married, State Name Used at that Time: Residence (at time of marriage): r-.,1 raas. t„r ~ ~ stria BrtdelGcoot~tS~ottse Name (as recorded on marriage license): Date of Birth: (err ay- at floc oI orripw Faf Iriddr last 9Ftl~ Nano If Previously Married, State Name Used at that lime: Residence (at time of marriage): r~ res. tar t:oa,ty afar. lUlarriagtr< nforntation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: 1~>~ Rid laver a IYl r 1~1~5 ~n scoot or ~ I, Purpose for which record is required: ~ Date of Marriage or Period ~, , n ~~~ ~ (~ ~ ~ C O ~ ~ ~~~ ~ ~ r~ Covered by Search: sa.aa floor In what capacity are you acting?: What is your relationship to person whose record is requ~ed? ~~~~~ (Itself, state'SELF'.) ~~ s..d- ~ ~.~.d+:gP.ra4 ~.iee~my- If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: Applicant's hone Number. - ~ 2 'lt ~-~I3- ~~~-~ Applicant: Please print name and address where record is to be sent: ~a ~ i P,(~ ~. ~(,(a~l S~-- Address of Applicant: yV~o~~ ~ 1 ~; NCI 12~a ~ ~1' State ZIP City Stetr ZIP vvnw ~ io/ i i f rape i of c NElill YORK STATE DEPARTMENT OF HEALTH Vitt Records Sedian Application to TotllmlCity Clerk for Copy of Marriage Record TYPE UF''REC4R© aE~iRf ©~ntfar Nf~tmbsr of Copies) Search and Fee t6f 0.0o Search and ,/ Fee $10.00 Certified Transcript per copy Certified Copy =^^ P~ SPY A Certified Transcript is an abstract from the marriage record issued under the A Certified Copy indudes all of the items of information ooarnng on the original seal dthe town/aty deck. It krdudes the names d the contracting pasties, their record of the manage. residence at the time the license was issued, date and place d marriage as well as date and place d birth of the bride and Boom. A Certified Copy may be needed where proof of parentage and certain otirer detailed iMamatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a marriage occurred. court proceedings, or settlement d an estate. i3ridelt3roomlSpouse Name (as recorded on marriage license): Date of Birth: ~~ ~~ ~ S ~ ~ ~,r ~ arr-w~. ~a ~ If Previously Married, State Name Used at that Time: Residence (at time of ma 'age): ~~ ~~ - \ ~ r~ ~. rr ~h i3ridei4~roomlSpot>rse Name (as recorded on marriage license): Date of Birth: ~ k•+aerr~e.a.rnyf eren ~. r-e.e ~ t rrds. r ' \ ~.r If Previously Married, State Name Used at that Time: Residence (at time of montage): Wa ~\ ~- l l s ~~ ~ ~ ~. ~ e d __ __ _ _ ___ _. __ MatTiage nf0rrttat~n Place Where Marriage License Was Issued: Place Where Manage Was Performed: Marriage Certificate No.: Local Registration No.: v J~v ' ~ y~u~P'~ ,~ra...r ~-~ Teem ar Toe~n a Purpose for which record is required: Date of Marriage or Period ~O G i ~ ~ [ (.f (I ~ Covered by Search: ~r C ~ '2~O - J s. In what capacity are you acting?: What is your relationship b person whose record is required? rti.,~ad~l~rl (If self, staff "SELF".) s..d- br ~rswrdigpwrsa) f.w/a1d/~7ry/ If attorney, give name and relati ship of your client to person whose record is ragas Signature of scant Date: Applicant's hone Number. Name of 'cant: Please print name and address where record is to be sent: Address of Applicarttt City Sfate ZIP Cdy SfaN ZIP DOH301 (8111) Pepe t of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records section Application to TownlCity Clerk for Copy of Marriage Record TYPE OF REC4R© QESiRE D ~Enter'Number of Cc3pies) Search and Fee t6t 0.00 Search and Fee $10.00 Certified Transcript per copy Certfied Copy D per copy A Certified Transcript is an abs7ad from ilia manage record issued under the A Certified Capy uidudes ap d the items d information occumng on the arigin~ seal d the townldty deck. It indudes the names d the ooMracting parties, their record d the marriage. residence at the time the lioenae was issued, date and place d marriage as well as date and place d birth d the lxide and Boom. A Certified Capy may be needed where proof d parentage and certain other detailed information may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a maniage occurred. court prooeerings, a settlement d an estate. BridelGroomlSpouse Name (as recorded on marriage license): Date of Birth: - >`s.r rear t„r ai<iB.w. -.LS - ~•'' ~~ OS If Previously Married, State Name Used at that Time: Residence (at time of marriage): .~ `/ 0 Fwrr ~add~ Laf Coin 8bN &idelGroomlSpouse Name (as recorded on marriage ficense): Date of Birth: Frt Ylddb I~rr airb Nrrr ~,~' - _2. - / r' i / If Previously Married, State Name Used at that Time: Residence (at time of marriage): rx.r r~adr. r,re acre. _. iNar: ris~t- nformation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: w~~~ 3as r ~ ~ ~~ ~ ;~ ~~~~~ Town or Tows a Purpose for which record is required: Date of Marriage or Period Covered by Search: f-, ~f dZSu :.~ti l%".~ ~ rj er.~ed.~r rr a..oM how: In what capacity are you acting?: What is your relationship to person whose record is required? ~~~~~ (IfseB, sta~'SELF'.) If attorney, give name and relationship of your client to person whose record is required: Signature d Applicant Date: Applit~M's hone Number. ~ - ~ ~j ~._ ~, , ..w.... Na of Applicant: Please print name and address where record is to be sent: a.. -. , ,, ~ . ~. Address of Applicarth .~~ _, jc, ~d:; ~_ City Slate ZIP City Sfax ZIP DOH301 (8111) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vitt Records Section Application to Town/City Clerk for Copy of Marriage Record TYPE 4F RECORD QEE~RE © {Enter f~lurnb~r of Copies) Search and Fee $~ o.oo t N er co Certified Transcri Search and Fee $f o.oo C rtifi d C ~ py p p per copy e e opy A Certified Transcript is an abstrad from the marriage record issued wider the A Certified Capy includes all of the items of information ooarmng on the original seal of the townIdly deck. It includes the names d the oadrading parties, their record of fie marriage. residence at the time the lioenae was issued, date and place d rnariage as weN as die and place of birth of the bride and geom. A Certified Copy may be needed where proof of parentage and certain other detailed infarmad5an may be required such as: passports, veteran's benefds , A Certfied Trarrsaipt may be used as proof that a rnamage aocu-red. nowt proceedings, ar settlement of an estate. BridelGroorNSp~use - Name (as recorded on marriage license): Date of Birth: lo-.y. ar t:.. ~..nty~ ~ ~. ~ and' .~N... ~~ ao_5 If Previously M rried, State Name Used at that Ti Residence (at time of marriage): Frsf YldiN !id Canty SI~Ar '&1delCrs~omttS~o~tse Name (as recorded on marriage license): Date of Birth: ~ra"arrrn.ernr~ Fad ~ MIDI ~ [err r ~ New ! ~ '+ 1 If Previousty Married, State Name Used at that Time: Residence (at time of mariage): r,..r waa. t..r aa. I~larrislge; lnforrri<ation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ ~Ol9J Vl Ae»oN ~~ Taws a• a Purpose for which reco is required: Date of Marriage or Period C Or .~~~5 ~~ J 10 covered by search: ~M« ~~ ~ 2 0 In what capacity are you acting?: What is your relationship to person whose record is required'T ~~ (If salt, staff "SEEP.) S ~ L~ ~~ If attorney, give na me an relationship of your client to person whose record is required: ~n t tr" Signature of r nt Date: ApplicattPs home Number. ' ~ ~ ~ '2~'-1 ~(~ -- ~ 4 Q - 2c~ 2`~ e o Please print name and address where recoM is to be sent: (~ 1 S ~ l~p/ Z~ Ad Tess of Applicant I ~(~ ~~ n~~l~ k P ~ ~ ~ ~ ~ ~ Stare ZIP Cdy Stab ZIP uun,~wi rain) rape i of z f NEW YORK STATE DEPARTMENT OF HEALTH 1!'rtal Records Sedian Application to TotilmlCity Clerk for Copy of Marriage Record TYPE CAF RI=G4Rfl aE~13E D (Ent~el~,lumber of Copies) Search and ^ Fee at o.00 er co Certified Transcri t Search and ^ Fee $t 0.00 er co C tifi d C py p p py opy p er e A Certified Transcript is an abstract from the manage record issued under the A Certified Capy itrdudes all d the items d infannedon occumng on the original seal d the townlcity dark. It indudes the naves d the oontrad'mg parties, their record d the marriage. residence at the time the license was issued, date ab place d marriage as web as date and place d birth d the bride and Boom. A Certified Capy may be needed where prod d parentage and certain other detailed infarrnatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as prod that a marriage occwred. court prooeerxngs, or settlement d an estate. BridelGroaml5pcuse Name (as recorded on marriage license): Date of Birth: /or,a.r~..~..rrt.~ If Previously Married, State Name Used at t~i~l ~ ~~ u'" Resi~den1ce,,(at time of marriage): ~~~-~1~55 ~ ~~ ~ Frd ~' tl~dde tail Como tfYle &idelGrootrttSpouse Name (as recorded on marriage license): Date of Birth: ~ C~ l ta-ewar~e.a.~.~ a.rl. . ~ s ~~~ -- ~ ~. t~ ~. nrlasi. If Previously Married, State Name Used at that Time: Residence (at time of marriage): \ ~~~~ ~.J twrr ~. t..r _. iVlarriage nforrktat~on Place Where Manage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ ~ ~ `" Teen ar ~ t Tows a ~ Purpose for which record is required: Date of Marriage or Period ~~ ` J ~ 't~~~ ~ ~~ Covered by Search: -7 In what capartity are you acting7: what ~ your relationship to person wtwse record is requa~ed? ~,~,b~~ (If self, state "SELF'.) ~ S..eurx ` ~se~olinyp~ie~ pm/dd/mry) If attorney, give name and relationship of your client to person whose record is required: natu of Applican Date: Appli s Phone Number. ~~~~ LI w ~z ~~ ~a-LQ~ ~~od b Nam of icant: Please print name and address where record is to be sent: ~`(~ ~ Ls ~~ n ~ ~~ u- -- na- , o Address of Applicar>x 1©~~-7 ~~2a~1 ~~ I~a~~7 l~o+~-?~J ~~ City State ZIP City SfaM ZIP DOH301 (8111) Pepe 1 of 2 i r Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Search and ^ Fee $10.00 Certification p~ cepy A Certification, an abstract from the marriage record issued under the seal of the Health Department, includes the names of the contrasting parries, their residerx~e at the ritrte the lirrense was issued as weU as date and place of birth of the bride and 9~• A Certification may be used as proof that a marriage occurred. PLEASE PRINT OR TYPE Fee $10.00 P~ ~Py of information Certified Transcript may be needed proof of gntage and 'n dst~iledarforna may be such ,'V 's ,court ~edinge, or W ~P~ER TOWN CI.E________ Name (Frs~ (MidlId__le) _ (Last) ~~ ~ ~ ~ µ~ ~ ° Name (Fast) (Middle) ~v;'l 61 el n (Last) rU1 C t oyi~1 L Groom 1 de B Groom's A orDateof~ aq ~ tq ~lgBg Bride's A a~°~ ~ ~ I ~ ~ ` 1988 Birri, ea Residence (Coup) {State) Residence (County) (State) s2 ~ R~sz mac °~ ~ ~-~a ~a Vic h - rr, .. Date of Mani or Period Covered Q $' `Z31 ZQ ~ 2 ff Bride P Married. State Name . b Search Used at That Tana LicenseVVase (,JppD~~f-~~~a,''s _ [ Marriage Was (~~PidlG~l°~S ! Fall s tJ ` Issued P~Fnrrned ~ what pu a; information required? Pes~~~c.a ,d~~l~~l~t c~sctS In what capacity are you Search and Cerrified Copy What is your releirionship b person whose record is requested? ff self, ~t~ts'eelf.' .5~1+ If attorney: Name and relationship of your client to persons whose marriage record is required. N ~If~~res ~, , s ~ ~ 1 ~'.. U~~~ VANESSA N. KELLEY ^ ~ NOTARY PUBLIC STATE OF FLORIDA -1~ Comm# EE181837 E JUN t. R 2J,2 TOWN OF WAppINGER TOWN CLERK LAW OFFICES 1VIARKOVITS ~ 1VIARKOVITS 12 EVERGREEN DRIVE P.O. BOX 2025 WILLIAM B. MARKOVITS (1905-1982) MIDDLETOWN, NY 10940 ROBERT L. MARKOVITS (845) 343-0505 BRENDA J. MILLER FAX #845-343-9008 NOT FOR SERVICE OF PROCESS June 7, 2012 Ms. Christine Fulton, Town Clerk 'Town of Wappinger 20 Middlebush Road Wappingers Falls, New York 12590 Re: Estate of Frank V. Incorvaia Dear Ms. Fulton: Thank you for your email of June 6`'', 2012. Please forward to this office a copy of the marriage license for Frank V. Incorvaia and Louise A. DeFillipo. Enclosed please find our check., in the sum of $10.00, to pay for the copy along with aself-addressed, stamped envelope. If you have any questions regarding this matter, please do not hesitate to contact ine. 'T'hank you. Very truly yours, BJM/ed enc. MARKOVITS & MARKOVITS BRENDA J. MI ER JUN 1 1 20-2 TOWN p~ wgpprNGER Application to Town/City Clerk Vaal R Oecords section EPARTMENT OF HEALTH for Gopy of Marriage Record search and ~ ~ s~o.oo Certification ~ ~y A Certification. an abstract from ~e marriage record issued under the seal of the Heallh Deperlment, includes the names of the contracting parties. their residence at the urns the bcense ores issued as well ~ date and place of bMh of the bride and groom. A Certification may be used ~ proof that s marriage occurred. search and ~'~Y Fee s~ o.oo certified ~ ~J per spy A Certified Trarrsrxipt incN~des ap of the items of intonnation oxurring on the original record ~ the marriage. A Csrfifisd Transcxipt may be needed where proof of parentage and certain other detailed irdorrrretion may be required such as: passports, veteran's benefits. court proceed. or seteement of an estate. PLEASE PRINT OR TYPE Name (Post) (Midge) (Lest! Name (Fusq (Middle) (last) c~aroom l-~1.~~,.GC.~, G• S1~-o..,~-on B~;de, N ~ c~cl~ So,v-1 ~ Groom's Age orDa~of 12(t7f fR$3 Brides Age ~ot a ~Z9/j°l$~. e Birth iru Residence (County) (State) Residence (Count) (Slats) sg `~~-c~ G -''`~ ~ `~~~c~..~-SS 1~`I - room, ~~ ~ or Period Covered ( ~3 2012 M Bride Previously Married. Stets Nsme o seerai Lissd at That Time Place Where was LJ ~n Place Where ~ t~o ~~5i~, ~P ~ For what purpose is inbnnation roquired? What is your reletiort~iip to person whose record is requested? ~n ~~1.SS ~ 1 r. ~ TAr~' K self, stabe'seN.• ~~ _ C In what capacit are you acting? ff attorrtey: Name and rsiatioriship of you client to persons w!tioss martiags r~eoord is required- Signahue%~ppMcaM Da1s ~~8~12 Address ~ Applicant Please print name and address where record is to be sent. ~~~.~+- cw n \1 ~ $`'( ~c ~ ~c,~o~-- 5 err: ~ x.,o 11 ~o~`S N~ 1 1 r I ZS`l 0 l ~`t r'own U^trw l~ ,. o.PP ~n e g (~ wa.pp~n~v-s t-~S N`{ 1259 d ~~~ (~~ . (PLEASE SEE REVERSE SIDE) Where to Apply for Record of Marriage t. License Issued in New York State (Outside of New York City) Year of Marriage * 1880 to present Apply to: Certification Unit Vital Records Section P.O. Box 2602 Albany, NY 12220-2602 * 1880 - 1907 and license issued in the cities of Albany, Buffalo . or Yonkers Albany: City Clerk, City Hall, Albany, NY 12207 Buffalo: City Clerk, City Hall, Buffalo, NY 14202 Yonkers: City Clerk City Hall Yonkers, NY 10701 2. License issued in New York City Apply to the Borough offixe of the New York City Clerk that issued the marriage license. The location of these offices foNows: Manhattan - Municipal Building, New York, NY 10007 &ooklyn - Municipal Building, Brooklyn, NY 11202 Bronx - (Records for 190&1913 are on file with the Manhattan office) 1780 Grand Concourse, New York, NY 10457 Queens - (Records prior to 1898 .are on file with the New York State Department of Health) 120-85 Queues Boulevard, Kew Gardens, Jamaica, NY 11424 Richmond - (Records prior to 1898 are on file with the New York State Department of Health) Borough Hall, St. George, Staten Island, NY 10301. PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. ~S~c' ~~Q ~ Application to Town/City Clerk ~~ R ORK STSA~rE~DDEPARTMENT OF HEALTH for Copy of Marriage Record Fee s~ coo ~ Fee s~ o.oo P~ ~Fy ''~ l~ c~Py A Certification. an abstract from the marriage record issued A Certified Transcript aN d the ilerns d intorrnation under the seal d the Health Departirrent, inckides the names d oxumng on the original record d the marriage. tl~e contracting parties, tl~eir residence at tl~e lima the ioenee was issued as weep as date and place d birth d the bride and A Certified Transcxipt maybe needed where proof of groom. parentage and certain other deleted ir>Forrn~on may be required such as: paesporfs, veleranh benefits. court A Certification may be used as prod Ihat a marriage oxurred. proceedRgs, or sefllement d ~ estate. PLEASE PRINT OR TYPE Name (First) (Middle) (I.aet) Name (First) (Middle) (Lash Groom r K+1h4- V~ +~ c ~ SAS fC~ ~ ~~' Z 1q B~ ~~n! ~+. ~ ~yc~ Groom s Age Bride's Age °~ y 3 5 - Y - ~ ~ e~ d ~ - S - ? ~ ~ ~- Residerxe (county) (Sts6e) Residence (County) (Stale) Groom ~~'c~-ss /~ Bride c~.~-~iusS ,,, Dots d Marriage ff Bride Previously ors ~ _ ~ 5 _ ~Z Married. Stale Name used at That Time Placs? Where ~SlJed Was ('`~PQ~`~:~-~-~ ~F~ ~ r-~'~ Place Where u~..:~,.~ ~ 'New C ( ..'°Performed~tl° OR-~`^~ ~~J Ccau~..~T~ •' N 7 For wjh~at purposeyis infonna6on required? Whets your relatiorrehip to person whose record is requested? " 1 _ S'ty''" ~°- cc~a Nom- "'~ p D I S~~ ~ ~~ SR ~ ~ • ~/ ~ ~ 1 In what ~ are you acting? ff allorrray: Name and relatior>sft~ d your diem to persons whose marriage r~acard is reputed. I`~ ~~~, ? ~t~tz v v . ~' ~rG~~~ ll~ ~~ w d {e F,~,tJ~ s .- Y / L~ f a record is to be sent. ( -- ~1- -- ~/,~ DOH-301 3/98) .~ (PLEASE SEE REVS SIDE) `~ Tp Jul ~ 3 ?01Z T N OF wAPPl AWN C~ERNGER K NEW YORK STATE DEPARTMENT OF HEALTH Application to Totitm/City Clerk for Copy of Marriage Record vital Records Sedian TYPE'f7F RECORD QEI~RE D tEnter Number of Copies) T Search and Fee $10.00 Certified Transcri t er co Search and ^ Fee $10.00 ' p p py Certfied Copy • per copy A Certified Transcript is an abstract fran the marriage record issued under the seal d the town/aty clerk. It includes the names d the oontrading parties, their A Certified Copy includes aA d the items d information ocatning on the anginal record d fie martiage. residence at the time the license was issued, date and place d manage as weN as date and place d birth d the bride and graarn. A Certified Copy may be needed where prod d parentage and certain other A Certified Transaipt may be used as prod that a marriage occrrxred. detailed irrfarmatian may be required such as: passports, veteran's benefits , oatrt proceedings, or settlement d an estate. BridelGroom/Spouse ' Name (as recorded on marriage license): Date of Birth: ~ e~nn ~ n L ~q~h v SSe ~~ ~aa•~~~ , , ~ nrra~s. ~, artir t+r.~. 1- ~ 2 " If Previously Monied, State Name Used at that Time: Residence (at time of marriage): F..d ter. `~ ~.~ ti `-~ sit. &idelGrootntS~aut:e `` Narne (as recorded on marriage license): Date of Birth: laea•err~e.a..ryf If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~~~ N ~ e~ Marriage lnfor~rtation .::;; ,.. Place ere Marria~ ' en~ Wa ed: Place W here Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ n I v~.~J~f~PI~~ d~'~,rt~o ~-~r ~~- Teen ar rew~ « Purpose for which record is required: Date of Marriage or Period l~~~J {~~- " Covered by Search: 1 Wrti~d~aa s..or- tray ~^ ~ ^ ( 2 In what capacity are you acting?: what is yore relationsh~ bo person whose record is requved? ~~~~~ ~ (If self, staff" ELF'.) W l S~ ~ ~ ~ r~/de/~- If attorney, give name and relationship of your client to person whose record is required: V` ` ~e rV~ ign furs of Appl' M Date: AppGcaM's hone Number, v N me Applica Please print name and address where record is to be sent: ~~ ~ ~ Y L U.A7~'~ I ~ Address of Applicar>C u-C ~~~~.1 ~~-' .--~- ~~~. ~ I- ll~ r ~ X251 ~ ~ , ~' Stets ZIP Cdy Stets Z1P uvnw i ~o/ i it rage i of t :~ .~„ ,,; - --- ~- --~ "NEW YORK STATE DEPARTMENT OF HEALTH vnat Reaads ~~ Application to Town/City Clerk for Copy of Marriage Record i TYPE OF REC~RD'is?ESiFiE D .(Ent®rNumber af'Capies) Search and Fee St o.00 Certified Transcript © per copy Search and Fee $10.00 Certified Copy ^ er co p py A Certified Transcript is an abstract fran the marriage recall issued under the seal d the towMaty deck. It includes the names d the osntrading parties, their A Certified Copy includes all d the items d information ocamng on the original recall d the marriage. residence ffi the time the license was issued, date and place d manage as rr¢tl as date and place d birth d the bride aid groom. A Certified Copy may be needed where prod d paentage aid certain otire r A Certified Transcript may be used as prod that a manage ocwrred. detatiCed irrfamatian may be regrtrced such as: passports, veteran's benefits , court prooaedrngs, a settlement of an estate. Bridelf3roomlSpouse Name (as recorded on marriage license): Date of Birth: ~1r1~~`c1 cJ~~h ~~~0 ~-.a..-r..~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~ Q v~-zlrv~sS ~~ Fist /~~ Vy Sir &idelGrE~omlSpouse Name (as recorded on marriage license): Date of Birth: paC'c~0 C\ ~7C~~~'~ ~ (a apo at 6ss of sir-isy~l _ ~ I ~ I Frst tYid~s !af Btrtl~ Nwn p d tf Previously Married, State Name Used at that Timer = ° - Residue (at tirrr~ of ri~attiage): (~ ~J~c.~nst-SS ~~j Marriage Inforrnatiort Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Manage Certificate No.: Local Registretion No.: ~r~ ~~~5 c~a~4 a~ 1 Pow h e- ~~ Pry Teen ar 1001 N . Purpose for which record is required: Date of Marriage or Period pas ~~°~, ~ ~a~ ~~an~ Covered by Search: If~risdeaa ~ ~Q ~ In what capacity are you acting?: What is your relationship to person whose recall is requved? ' 1 fM/dd/rm~i! (If self, sta~ SEL ~.) a ` srealx J2~ ` Is-at~l Fr/ad/mrl If attorney, give name and relationship of your client to person whose record is required: .~__ Signature pelican Date: ~~.~ -~~3 r ~ z Applicant's Phone Number. ~y5-235-0(03. Name of A rant: PPi Please print name and address where record is to be sent: n- ~nS~'r1 l~O~c~~~j ~. i~ Address o f Applicant ~( l~ \J~~~11.~ ~ C k. ~c, ° ICJ '[ ~ 2~ ~Y SFate ZIP City Sleta ZIP DOH~01 18/111 Peae 1 of ? ,~ IR Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage - * 1881 to present ($10.00 per copy) * 1881. to present (530.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 1.2207 - . .Buffalo: city Clerk. - 65 Niagara Square _ _..._~., .. ,,...-. . .. _ Buffalo, NY 14202 _ __ _ , _ Yonkers: City Eierk _ _ 40 S .Broadway Rm 107 Yonkers; NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.diyder>tinycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOFI,9o1 (8/11) Pepe 2 of 2 NEW YORK STATE DEPARTMENT of HEALTH Application to Town/City Clerk for Copy of Marriage Record vital Records Section TYPE C!F RECORD>C~E~#RE b tFErttalf `~I~mber of 'Copi+ss) - Search and Fee 310.00 Certified Transcri t er Search and ^ Fee $t o.oo p p copy Certified Copy per copy A Certified Transaipt is an abstract from iFre marriage record issued under the A Certified Capy mdudes aN d the items of infarrnation occumng on the original seal of the townldty dark. ft indudes the names of the contracting parties, ttreir record of the rnamage. residence at the time the license was issued, date and place d marriage as well as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other A Certified Transaipt may be used as proof that a marriage aocurted. detailed intarnatian may be requtred such as: passports, veteran's benefits, court procaedrngs, err settlerrernt of an estate. &ide{ room/Spouse e (as recorded on marriage license): Date of Birth: +-r~ 8 ~ ~ ~~, a .-~_~ b If Previously Mam ,State Name Used at that T ime: Residence (at time of marriage): f t t=.,t ~. t,.r ~1~~2e t~, Ste, &ide r tree Name (as rded on marriage license): Date of Birth: ~ ~ ~ ~ ~ o I«.y..rr..a..ryy ~ tridei. t«t f e:eb sr... If Previously Monied, State Name Used at that Time: Residence (at time of martiage): r=..r rr~ ~ am. Marriage lnforrttation ', Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Martiage Certificate No.: Local Registration No.: ~ ~~ ~ ~-~ A~ r..e« ; rowr« Purpose for which orri is required: Date of Marriage or Period ~I /~ „ ,1 Covered by Saarch: l 1~.,>/V V w~ia.w« In what capacity ate you acting?: t rs you relationship to person whose retard is requaed? (If self, state "SELF'.) ~~~~~ S..aa br Ira-+.r+~aw-~ ~Idd/mr- If attorney, give name and relationship of your client to person whose record is mired: Signature of Applicant Date: Applicant's hone Number. Name of Applicant: Please print name and address where record is to be sent: Address of Applicant: ~ ' 1 State ZIP ~..~, ,. City Stab ZIP ~..~ ~~,,, ~ ~,,, ~ ~~ Hoye ~ ~~ Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) * 1881 to present (530.00 pe- copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. Apply to: Town or City Clerk Where license was issued (purchased) New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/vita/ records/marriage.him Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information rf the marriage license was issued in any of the five boroughs of New York City: www.dtyds-~lcnyc gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1888 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. cof+~o~ ten ~l ~e z a z }, .~,~ ~ ,. qe ~ ~ , ~;. ~ SSV~~ ~~ ~ 8~~ ~H ., ~S~I ZS ` NEW YORK STATE DEPARTMENT OF HEALTH Application to TottlmlCity Clerk for Copy of Marriage Record Yrtal Records section TYPE UI= t~ECORD QE~FtED (Enter fl~mber of C~~i~es) Search and Fee 310.00 ef SPY ^ Search and Fee 310.00 per copy Certfeed Co P Certified Transcript py A Certified Transcript is an abstract tram the marriage record issued under the A Certified Capy indudes all of the items of infannation occurring an the original seal of the tawnlcity dark. It mdudes the names of the contracting parties, their record of the marriage. residence at the time the fioense was issued, date and place d manage as well as date and place of tHrth of the bride and Boom. A Certified Capy may be needed where proof of parentage and certain other detailed information mary be required such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a manage occurred. court proceedings, ar settlement of an estate. . Sridel(3roo~lSQoase Name (as recorded on marriage license): ~ ~ _ ~}1~ ~p1r~,~,~ ~ ~ ~~ Date of Birth: fwapatfw~ole~rt~ ` , I 1 S ~~ t~ ~ ~~ If Previously Married, State Name Used at that Time:. Residence (at time of mamage): ~'f l srr. r„r Fist ~~ Br'Ide{~rOOt~if~OtISB Name (as recorded on marriage license): Date of Birth: (aay~dtiw.Nerrig~ r~ ~ v n trr~ N.» y I `I ~~ If Previous y Married, State Name Used at that Time: Residerx;e (at time of marriage) h, ~~'~~ 'v ' r~ ~, t,.r Marriage Irtformatiort Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~-~ p~ l~~ ~ ~ S ~, s ~ ~ c.~jro.~ ~ • ~,~..~,~L...~ N Purpose for which record is required: o.~N Date of Marriage or Period Covered by Search: ~US S ~~ <~ ~G.~r~ C,~,r~ r~c~ r.~.d«~a b r a reia mer In what capacity are you acting?: What is your relationship tp person whose record is required? ~,,,,~~~~ ' " SELF .) (If self, state sAw.~ kr z.\ ~ Pr+~www~~i Eewlddl)7A~) If attorney, give name and relationship of your client to person whose record is required: 1 ~~~ ~~- ~ ~2 ~ `~ ~ ~ 1~~~ ~ 3 Sighature of A pliant Date: Applicant's hone Number. ~an~- nn Name of Appli nt: Please print name and address where record is to be sent: n Address of Applicar>C \ ~ s 33 Cify Stets ZIP City Ste& ZIP DOH~Ot (8111) Pepe 1 of 2 t~TE~V YORK ST ~~,; ~ ~ ~a ~ ~,;, ~. fi#-1 4 +~ J 168th: es>is-42 ~~-t5-~~ w~aaww A NEW YORK STATE DEPARTMEWT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vita' Records section TYPE 'OF IEGORta ~3E~fRE Q (Enter Number of Cc3pies) Search and Fee S~ o.oo ~ ef S Search and ^ Fee $~ o.oo per copy Certified Co PY P Certfied Transcript py A Certified Transaipt is an abstract from the marriage record issued under the A Certified Capy indudes all d the items d information occurring on the original seal dthe town/aty dark. It indudes the names d the oontrac~g parties, their record d the marriage. residence at the time the license was issued, date and place of marriage as weY as date and place d birth d the bride and groom. A Certified Copy may be needed where prod d parentage and certain other detailed infarrnatian may be required such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a marriage ooatrred. court prooeedirrgs, or settlement d an estate. $rit~ GrOt)Itt/SpOUSe ame (as recorded on marriage license): Date of Birth: F~ I f~dde Lad tai NaN If Previously Married, State Name Used at that Time: Residence (at time of arriage): ~U~~eSS ~~ Fnf M'idde lad Cam' Bridal r t><se Name (as recorded on marriage license): _ Date of Birth:_ Fief Mode !f Previously Married, State Name Used at that Time: Residence (at time of manage): w~'ch S S r~ ~ ~d Manage to#.arrnattoa __ Manage Certificate No.: Local Registration No.: omted: erf Place Where Marriage License Was Issued: Place Where Marriage Was P II ` ~ ' l- l~ t I . ~ .J ~h Iw-~V Mb~M r n e~'S v e s5 ~n c ( C~ •'s I U lCl'~ 3~ r ,t~ -~ ~ 5 w TqM Tew~ Purpose for which recorcl is required: Date of Marriage or Period Covered by Searoh: Y~rieda-a Saanb iow: ~ In what capacity are you acting?: What is your relationship to person whose record is requred? " ~ ~~ (~ ~ \ SEEP.) (If self, state Swab for If attorney, give name and relationship of your client to person whose ter~rd is required: ignature d Applicant ate: Applicant's Phone Number. Name of Appli nt: Please print name and address where record is to be sent: ~~''~ S e ~~~ v Address of Applicant: i /Y~m ~ ~ i 9P ~/~ ~ . c / ~,ry a ZIP Ciry State ZIP DOH~301 18J11) Page 1 of 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. 2. License Issued in New York City New York State Department of Health Vital Records Cert~cation Unit P.O. Box 2602 Albany, NY 12220-2602 wr-rw health.ny.go-r/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: wrNw.dtydsrttc nyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. pOF1,901 (BI11) Pape 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH vital Records Sedian Application to TownlCity Clerk for Copy of Marriage Record TYPE 4F R~~ORD i3E$iFiE D Enter fVumber of C pies) Search and ~ Fee $~ 0.00 C rtifi d T i t Pef SPY Search and ~ Fee $t o.oo er co Certfied C e ranscr p e py opy p A Certified Transaipt is an abstract from the manage record issued under the A Certified Capy indudes all of the items of information occurring on the anginal seal of the town~dty deck. It indudes the names of the oontrading parties, their reoaM of the marriage. residence at the time the license was issued, date and place d manage as well as date aM place d birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other detailed irrforrrraban may be required such as: passports, veteran's benefits , A Certified Transcript may be used as proof that a marriage occurred. court prooeedmgs, a settlement of an estate. Bridel(3roarblSpause Name (as recorded on marriage license): Date of Birth: ~ ~~ taaa~. ~ a:wN... v If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~~ ~~~ ~~ Fwat Itfid~ !af CouMy 86N &ide/Grootxt/Spa~sse Name (as recorded on marriage license): Date of Birth: ~ `r ~~ M~c~~~~ ~ Ian I~ ~ ~ ~~. If Previously Married, State Name Used at that Time: Residence (at time of marriage): r~..r t+r-au. t,.r ~+ _ .... _ _ ...... Mt;trriage trtfo~ttation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ 1~. 7ewr a row « Purpose for which record is required: Date of Marriage or Period G-~~r~~ ~ ~ fi Covered by Search: ~ ~~ ~~ ~~ In what capacity are you acting?: What is your rely hip to person whose record is requred? ~~~~ ~ (If self, slate "SELF'.) srdr rx ~~ ~~p.riq Nw/ee/)7111 If attorney, give name and relationship of your client to person whose record is required: S' ture of Applicant Date: Applicant's hone Num r. l 1 Name of Applicant: Please print name and address where record is to be sent: Address of Applicant: NOV 3 0 2012 c ER City State ZIP City ZIP DOH-301 (6/11) Page 10} 2 r N~iN YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record 1 - veal Records Sedicn T1(PE O€ f~~COf~D DE~iRE D {Eni~er N~rnlt~er at tc~ptesj Search and Fee $t 0.00 ^ P~ SPY Search and Fee $10.00 Certified Copy ^ Per copy Certrfied Transcript A Certified Transaipt is an abstract frtxn the manage record issued under the A Certified Copy includes all d the items of infamtation occurring on the original seal of the townldty dark. It includes the names of the axttradtng parties. their record of the marriage. residence at the time the license was issued, date and place of marriage as well as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other ' s benefits , detailed mftxmaticn may be required sudr as: passports, veteraur A Certified Transaipt may be used as proof that a marriage occurred. court proceerings, a settlement of an estate. 8ride!(3room/Spouse Name (as recorded on marriage license): Date of Birth: (orewatfiaorernvy~J .. ~. / ! +' ~~~ r! erenw^. / j~' !~ ~ i' I (~ ' . ~ ` 1 tar ~.r ~os~. P.~ rriage): If Previously Marred, Stat Name Used at that Time: Residence (at time of ma r CouMt, ~i rCJ~resf Stetr I Fra< idle lur Sri¢elGrootntS~ouse Name (as recorded on marriage license): Date of Birth: rniaf p..y..rr.~.e<. / J/ , 1 ~ W r>1s ' ~~IS~ ern w^. l z Z Za ~ Z ~'r ~ r n r . . ras, ry.r /~ ma 'age): of If Previously Married, State Name Used at that Time: Residence (at time / ~ 1: ~ ~~f> aw. /~ IJ , ~ rnr ~ tar Marriage tnforrttation , Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: iN~ jI / l ~~ ~ IA (f ~FI' U~I(~~ ioewa ~5f" ~E./ ~~~ 1 7ow~a Purpose for which ord is required: Date of Marriage or Period Covered by Search: I,~~r~ ~11fu~.,~e ~~ 1D~3~/z In what capacity are you acting?: <Nhat ~ Y~ relationship to person whose record is required? pe.~~~~ ' ' .) SELF (If self, state ~~ I ~ 5 ~ ~ f ~- «.,,~,~ If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: ApplicanCs Phone Number. e i Please print name and address where record is to be sent: ~ r~ ~ c.Tf e.T~.~ !<~ ~~~~ Address of Applica v ~ Gl^~ Ise ~ ~w a ~ ~ W C ~~~ ls~ ~. C ~: ~J ~ ; ~ ~~5 r !/s N ~ zs ~9 ~ ~ ~ ~ ~. 11 ~ ~ ' /zs y'~ - , ~~, SMte ZIP Cdy Slet~ ZIP DOH301 18111) Pepe t of 2 Where to Apply for Record of Marriage 1. License Issued in New York State {Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. 2. License Issued in New York City New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vita/ records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.cityder~nyc gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEV1l-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. pOF1,901 (8111) Page 2 of 2 ~ ~ p , e~i ~. ~; E ~+ ~ ~ ~ 4 .~~. r ^i~' ~ ~,. i~ :. ,., ~ 1'~c°FY' r ~ ~ A ~ ~r 3~ _ ,y ~R„~ ~~ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to TotitmlCity Clerk for Copy of Marriage Record TYPE (~F REGt3Rfl DESfFiE ~ (Enter NWmber of Copies) Search and Fee $t o.oo Search and Fee $t o.oo Certified Transcript ^ Pef SPY Certfied Copy per copy A Certified Trar-saipt is an abstract from the marriage record issued under the A Certified Capy includes ag d the items d irdtxmation ocauring on the original seal d the townlaty clerk. It includes the names d the ooMracling parties, their record d the marriage. residence at the time the lioenae was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Capy may be needed where prod d parentage and certain other detailed irrfarmaUan may be required such as: passports, treteran's bene!fils , A Certified Transaipt may be used as prod that a marriage occurred. court prooaedmgs, ar settlement d an estate. $ridef(3roomlSpouse Name (as recorded on marriage license): Date of Birth: 1 ~~ 0 N~ ' ' /orey~dtirofe-sriyy ~ s. Z~l I C~~~ ai:atre.. C ~ ~ ~ G 3 , If Previously Marri ,State Name Used at that Time: (at time of marriage): Residence ' 1 ~ l~~ /~' ~ nr~ar. ~ aa. - / ~r BeideliGroomtS~attse Name (as recorded on marriage license): Date of Birth: Iar aye at tteN of wr~iyy moose h ~~ c ~ ro -~'~G'{s ~ a~ lfl l~~~ ~~ ~ o ~ If Previously Married, State Name Used at that Time: nce (at time of martiage): Reside l ~1TC ~ ~ trrrrs. t,.r sa. , 'Marriage nforrttation Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~/ I h t'~S t~-~••r ~~ ~~ ~ nn f ~, Y ~ L r Q ro.ea ~ T~. Purpose for whit ord s required: Date of Marriage or Period NQ~ ~ Covered by Search: ~ ~. ~ ~~ ~~~ z, ~ ~~z In what capacity are you acting7: What is your relationship 1n person whose retard is requ~ed9 r1e,~~~~ (If salt, state "SELF.) S~ J ( s..en kr la+~rw~t- F~ledimrl If attorney, give name and relationship of your client to person whose record is required: Signature of Appli nt Date: / - ~ ` ~//7 /~ Applicant's hone Number. / ~ iLY~ Name of Appli nt: Please nt narr~a _ a is to be sent: Address of Applicant: ~ ~ ~ NOV Z n~~ p 7 2 S TOWN ®i=' W z S` -----__ w~ CLERK ~ ~ ~ , _ _ City Stets ZIP City Stets ZIP DOH-901 (eltt) Pepe t of 2 NEW YORK STATE DEPARTMENT OF HEALTH V11~1 QY/YYfrC CnNIM Application to TotitmlCity Clerk for Copy of Marriage Record TYPE OF RECORD DrE~FiE~ (Enter Number of Copies) Search and Fee at o.00 ^ P~ SPY " Search and Fee ~10.00 per copy Certfied Co rfied Transcript Cert py A Certified Tra-saipt is an abs7ad from the marriage record issued under the A Certified Capy indudes aA d the items d information orxruring on the original seal d the townldty deck. It mdudes the names d the contracting parties, their record d the marriage. residence at the time the license was issued, date and pace d manage as weA as date and place d birth of the bride aid groom. A Certified Copy may be needed where prod d parentage and certain dher detailred irrformatian may be requrced such as: passports, veteran's benefits , A Certified Transaipt may be used as prod that a manage occurred. court prooaedings, or settlement d an estate. Bridel(3room15pouse Name (as recorded on marriage license): Date of Birth: t~ 51~ l `K ~ forte*trrol..rly~- o S~S" 3 ~ I o taxer nr.~. Fr,.r ~..~ C~ rms. ~ ~ / o .! If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~l G ~cSS ~~ ~ ~, r„r ~y &idel~root~ouse Name (as recorded on marriage license): Date of Birth: ~ ~~~ (err aoa ore fie er er~iyy ~~ ~~ Fear ~ feeds. ~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): F.ae ~• t.~e Bean Mamage Information Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~~?~~~C~~/L ~~~~ W~~~II- ~ur~~ a~ A~ Teas a t'owr a Purpose for which record is required: Date of Marriage or Period Covered by Search: '-00 /~ G Brats tiger In what capacity are you acting?: What ~ y°or ~ ~ ~ ~ P~ whose record rs required? ' " ~„"~dd~~ .) „ SE LF (If self, state ~ C G L ~ s.ran ~ le~%wt>~ t~/mimyl If attorney, give name and relationship of your client to person whose record is r+a~tired: ign ture of Applicant Date: A ~caM's Phone Number. ~ ~~s~ ~3~ -~f3~. Na o nt: Please print name and address where record is to be sent: r o a ~r~ ~-~ ~~ ~ Q . ~~~~~~~ r~, ~. y Address d Applicant: ~~~- ~-`~ Ps r~ N ~l ~~~ ~3 ~, ZIP City 5~ ZIP DOH~301 (Bltt) Pepe 1 or 2 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881. to present ($30.00 per copy) If a state issued copy is required or you are not certain~in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Cert'rfication Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: ryryYydtyder~nyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx pu~~ (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. poF1,901 (8111) Pape 2 of 2 ~' ,~ ~' ^- NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vital Records Section - - -- -- - - TYPE ©F'RECORD ~ESiFE D (Enter Number of Gc~piies) Search and Fee $to.oo er co ^ Search and Fee $~o.oo per copy Certified Co py P Certrfied Transcript py A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy indudes all of the items of information occurring an the original seal of the townlcity deck. It indudes the names of the controlling parties, their reooM of the marriage. residence at the time the license was issued, date and place of marriage as weN as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other ' s benefits , detailed infartnatian may be rearmed such as: passports, veteran A Certified Transcript may be used as proof ihffi a martiage aocured. court prooeedrngs, a settlement of an Made. BridelGrtwrnlSpouse Name (as corded on marriage license): Date of Birth: (aayr.rrw.ofarniy.) ~ z~~~ c ~ ~' u~ ,~ w\ . c r cc / o~ 14l ~Z Fill Yidas Leif Birr-Nwr If Previously Marred, State Name Used at that Time: Residence (at time of maniage): ~u~-c- ~s S N y Fist ~'~ l~ ~1' ~ Bctd@~lrsrOOt4lIS~OUtsB Name (as recorded on marriage license): Date of Birth: ~t z w.c~,rc,l L la-+y.,r rw» or..,iy~- ,~ /~ /-~`~SS~ /4nn ~~!`g~g~ If Prewously Martied, State Name Used at that Time: La,f Residence (at time of marriage): La~ r~ 'Marriage fnwrtratian Place Where Marriage License Was Issued: Place Where Manage Was Performed: Marriage Certificate No.: Local Registration No.: A-~V ~-ta°'"-I Tew~ ar Toaw e< Purpose for which record is required: Date of Marriage or Period ) Covered by Search: ChQ.vl~- l~(i~-wJL_ ~''~ i~~SS~~ ^~ Wrwdoaa Ss~ah wnw: whose recall is requred? fe.,~dd~m~ri' n In what capacity are you acting?: What is your relationship to perso " (If self, state / ' SEEP.) Se l s..a-~ T ~is.neAi~ypNio~ few/dd1»771 of your client to person whose record is mired: If attorney, give name and relationship / 1'Vl~ ate: -. ignature of Applica AppGcaM's Phone Number. ~ - ~ y -I~~b112 c~'~ S Sys ~9~-2Bf Name of Applicant: ~ ja,~ ~cti2 w~a.,,e I~ Please print name and address where record is to be sent: 9 i'1'l Unf'~r'~ ~/UO Ps ~~ Address of Applicant: D ~~~ (,J~~,,,..~,- self NY r ZS'4 o V LS ~~ v Tom" 6 2012 ppINGER TOW N_ CLERK ~~, State Z1P City Stets ZIP DOH301 (alit) Pape 1 of 2 .. ,r s Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present (x30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. 2. License Issued in New York City New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.health.ny.gov/vital records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 Contact the office of the New York City Clerk for information if the marriage license was issued in any of the five boroughs of New York City: www.dtyderk.nyc.gov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE' Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. poH,90t (8/t t) Pape 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Yrt~ Records 5ecsan TYPE OF I~ECORIa DE~RE~ (Erlt+er Number v# Copies) Search and Fee $10.00 ^ Search and Fee $10.00 per copy d Co tifi C Per copy Certified Transcript py e er A Certified Transact is an abstract from ore marriage record issued under the A Certified Capy indudes aB of the items of inforrnatian occurring on the angind seal of the townldty deck. It mdudes the names of the oorrb'ading parties, their record of the marriage. residence ffi the time the lionise was issued, date and place d manage as well as date and place of birth of the bride and groom. A Certified Copy may be needed where proof of parentage and certain other ' s benefits , detailed infannffiion may be requrced such as: passports, veteran A Certified Transaipt may be used as proof thffi a marriage aoatrred. omit prooeefings, a settlement d an estate. `$ridel(3roo~nt5pouse Name (as recorded o'n marriage license): Date of Birth: ~/ D2 ~ S ~, v ,~, ,.~ .~,,a,r,,,, If Previously Monied, State Name Used at that Time: Residence (at time of marriage): D~rr~~f~.SS, ~/ f f Fief ~ !.M a i . ~P 'BridelGrooatlSpause Name (as recorded on maniage license): ` Date of Birth: ~l~il/lS Nl/~CoG~oS r t,,.a..rr~..r 7"oN ~~~ ~ ~ ~~ ~~~~6, oT~~ls ~ a ,~~ ~~ If Previously Mamed, State Name Used at that Time: Residence (at time of ma 'age): ~Dd1~S ~i'3n/A(~/D ~fI~1S Dr.~l` NESS, Ov » ~. Marris#~e lnforrnation Place Where Marriage License Was Issued: Place Where Marriage Was Perfonnec~ Maniage Certificate No.: Local Registration No.: s ~ ~/~f~//tl ~ ~s ~~GCS A~ ~~ r"~ cc ~ ~~ `~~rti ~ ~n s Tewr a 7ewr a Purpose for which record is required: Date of Marriage or Period Covered by Search: ~~-,~~~~ ,D~s~y ~o o~~~JN~- ~ ,~ ~~ aoo In what capacity are you acting?: tMret ~ Y~ relationship to person whose record is requkeed? ~~~~ ' SELP.) (If self, state s ~~~_ ~~ If attorney, give na nd relationship of your client to person whose record is required: Signature r t Date: App~icant's,r~ne Number. ~9~ ~ ~~9 ~ - ~ / ~~rd ~s Name o Applicant: ~ Please print name and address where record is to be sent: ~~~~ y~ ~~~ ~r~ ~o _ ~S ~~ ` si'~ ,a c Address of Applica . /590 TOW ~~, State ZIP Cdy _......., ZIP DOH~Ot 18111) Pepe t of 2 y i N ~' -. _ ~,..~....~.¢.~...-.s~Sti.~''~Gn x3t~`_.'-+(14 y-~r.]iri... ~c.~.l_~c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Application to TotilmlCity Clerk for Copy of Marriage Record TYPE OF i~ECORf7 QE~#REi ) (En#~ar Number Qf Cvpies) Search and ^ Fee t6~ o.oo Pei SPY Search and ^ Fee $t o.oo Per SPY Certified Co Certified Transcript py A Certified Transaipt is an abstract iram the marriage record issued under the A Certified Capy includes all d the items d infannffiian occumng on the original seal d the towr-Icity clerk. It includes the names d the oartrading parties, their record d the marriage. residence ffi the time the license was issued, dffie and place d marriage as weN as date and place d birth d the bride and Boom. A Certified Capy may be needed where prod d parentage and certain other detai{ed irrfarmaitian may be requrced such as: passports, veteran's benefits , A Certified Trarrsaipt may be used as prod thffi a menage occurred. court proceedings, ar settlement d an estate. . BrideFf3roomFSpouse Name (as recorded on marriage license): ~ ~ ~ ~,(~.~k. ~ ~~ ~f' ~i?~~-C ~'~~S I ~ ~~~'~ ~ ~ Date of Birth: h-+D++rirdeynLyy ~ ~~, , ~ C~ ~ C ~ ~ ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): ~~_~..~~~)"-~/' ~ Get= (l/~ C. ~~ Fisr IRds~ Lpf si ~ 8ridelCraomF~o~sse Name (as recorded on marriage license): Date of Birth: ~. ~ ~~ if Previously Monied, State Name Used at that Time: Residence (at time of m Triage): i ~-~~~~- CCtic ~~~( F.,r aredr, t,.r Marriage trtforretstion Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: r Purpose for which record,i~ required: Date of Marriage or Period Covered by Search: rt~.d«~o. In what capacity a yo acting?: Whet is your relationship to person whose record is requ~ed? ' " f,,.,~~~~ ~~ ~'~ SELF .) (If seK, sfa(~ ~ , C - d--~' ~~aare4 l~/ddinrt9 If attorney, give name and relationship of your client to person whose record is required: Signature d.~-pplicant Date: Applit~rtt's Phone Number. Name Applicant Please pri name and address where record is to be sent: _ Address of Applicant , ~ ~ ,l ~ ~~ ~' SMte ZIP Cdy ~ ZIP DOH~01 (eltt) Page 1 of 2 [:. 9 Where to Apply for Record of Marriage 1. License Issued in New York State (Outside of New York City) Year of Marriage * 1881 to present ($10.00 per copy) Apply to: Town or City Clerk Where license was issued (purchased) * 1881 to present ($30.00 per copy) If a state issued copy is required or you are not certain in which city or town outside of New York City the license was issued. * 1880 - 1907 and license issued in the cities of Albany, Buffalo or Yonkers. New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 www.hea/th.ny.gov/viial records/marriage.htm Albany: City Clerk City Hall - 24 Eagle St Rm 202 Albany, NY 12207 Buffalo: City Clerk 65 Niagara Square Buffalo, NY 14202 Yonkers: City Clerk 40 S Broadway Rm 107 Yonkers, NY 10701 2. License Issued in New York City Contact the office of the New York City Clerk for information "rf the marriage license was issued in any of the five boroughs of New York City: www.atyderrc.nycgov Manhattan City Clerk of New York 141 Worth Street New York, NY 10013 (212) NEW-YORK / (212) 639-9675 Brooklyn (also known as Kings) Bronx Queens (Records prior to 1898 are on file with the New York State Department of Health) Richmond (also known as Staten Island) (Records prior to 1898 are on file with the New York State Department of Health) PLEASE NOTE: Records of marriages in areas of the present City of New York, which were not part of the city at the time of marriage, are on file with the State Department of Health. DOH,901 (elt 1) Page 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Sedian Application to TotitmlCity Clerk for Copy of Marriage Record TYPE 4F #~ECOFID L~E~REL1(Enter f+lurnber of Copies) Search and ^ Fee $7O.o0 Certrfied Transcri er co t Search and ^ Fee $70.00 C fi d C py p p ert e opy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Copy indudes an d the items d infamatian ocauring on the original seal d the town/city dark. It indudes the names d the contracting parties, their record d the marriage. residence at the time the license was issued, date and place d manage as weU as date and place d birth d the bride and Boom. A Certified Copy may be needed where prod d parentage and certain other detailed irdarmaticn may be resftured such as: passports, saeteran's benefits , A Certified Transcript may be used as prod that a marriage occurred. oast prooeedmgs, ar settlement d an estate. Bride~Groom#Spouse Name (as recorded on marriage license): Date of Birth: ~'~a rh es j o$'Qa'1 ~o /IU. n np h-~Parie. dw.rfipJ , I~~~~~ Fr,r rwa~. ~t arlwtw.~. >~ If Previously Married, State Name Used at that Time: Residence (at time of martiage): ,~,.Ec 4 cI'S ~tl~ r~r ~asr t„r caaarr arc. &de#~room#S~cluss3 N ame (as recorded on marriag e li cense): Date of Birth: A l A _ ~( 1~``i~f~ ~ /-'~'~ICC fY~Q /1C // "~ (a+D~d6MOfw~niy~1 ~ a 2/ 11 / Fnf t~6ddr tpf B'ilb Na / , If Previously Married, State Name Used at that Time: Residence (at time of marriage): Fa.r srdw. tarf ass. _ _. Marriage Irfforrttatt+~n Place Where Marriage License Was Issued: Place W h ere Marriage Was Performed: Marriage Certificate No.: Local Registration No.: (,J~PP~,~¢rS ~vt-c4<zrJ /n ~ ~t/¢wi'~~~t ptawwly p~ Tew~ ar Teas • Purpose for which record is required: Date of Marriage or Period Covered by Search: Mniadena Sa~aM iaNC I I ~ ~o f In what capacity are you acting?: Whet is your relationship to person whose record is requrded? . . a ~~~'"'~ (If self, state "SELF .) ~% ~ Sweh br ~+~t~~ /~/dd/1711') If attorney, give name and relationship of your client to person whose record is required: Signs re of Applicant Date: AppGcaM's hone Number. Name of Applicant: Please print name and address where record is to be sent: ~Gri,af ~onknno Address of Applicant: l~rtdc~ ~~ ~°`PP~ ~9~~ ~~ (Is N~ (ZSgo City Stare ZIP CAy Stator ZIP uvnvu ~ la ~ ~) rape i o~ c ~~c~ - ~[a- $~ ~ ~~ cum - ;, ;. _, , ~ :~~ ~. 'lt=1 ~,~fi +1, ~'~ : . ~ ~' x ~~ <-.._ ~,.• i~------ =~ 11: tY--t4-06 B141F~S t t -17-1~ as~ur4~'Qt ~, F:- .. ~~ ~:. ---_ NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record . Vital Records Section -~ ~- TYPE'OF #~~CQRD L71ERED (En#e~r Number of C~piss) Search and ^ Fee a10.00 Certified Transcript per copy A Certified Transcript is an at>sa~t tram the manage record issued under the seal tithe form/city deck. It indudes the names d the contracting parties, that residence at the time the license was issued, date and place d manage as well as date and place d forth d the bride and groom. A Certified Transaipt may be used as prod that a marriage accurted $tda<Groom/Spouse Name (as recorded on marriage license): Search and ^ Fee $10.00 Certfied Copy per copy A Certified Capy indudes all d the items d information ocauring an the original record d the maniage. A Certified Copy may be needed where prod d parentage and certain other detailred information may be required such as: passports, veteran's benefits , court proceedings, or settlement d an estate. Date of Birth: F.~t f 1~, ~. ~C~`~II~ • t„r ~ 1 Clllf o errr,,r,,,, ~ l 7 ~~ If Previously Marred, State Name Used at that Time: Residence (at time of mama ~13 ~Jcr-i'h S ~- ~u ~'p ~~5 F..r ~sr e,~ w (WPBS. arc. &idet~rciomlSpouse Name (as recorded on marriage license): Date of Birth: /or aye at t~- o/ arrri~y~J If Previously Married, State Name Used at that Time: Residence (at time of marriage): F.st trades. r~.e aMr _.. Manage Inforrt~ation Place Where Marriage License Was Issued: Place Where Marriage Was Perfonned: Marriage Certificate No.: Local Registration No.: ~~ v1~QrS ~r4C~`e~ latxl ~ou~'~i'~. D~c~~ per ~~'- Tows a Twn a Purpose for which record is required: ~ Date of Marriage or Period Covered by Searoh: Maid oa a s..oM iow: / ~~~ 2 . In what capacity are you acting?: What a your relationship to person whose recall is requved? ~,~,pt~~ (If salt, sta~ 4P,~) I~t-1 s..d-~ ~fsrdirypMio~ «aw/till/>~ If attorney, give name and relationship of your client to person whose record is required: ~ignaiure or Appicam uaie~ ~eti~~. Pan~al~~ Address of Applicant: ~~ ~ ~ S~" ~-Is zs~~ 'lease print name and address where record is to be sent: t 3 ~or~ s~- wq~ ~~ ~ ~ 25~v, ~~ ~ Cdy Strafe ZIP I City Stets ZIP DOH301 (8111) Page 1 of 2 ~1V ~ ~W= . Y Kli ~~ 1 Al ~~ ~.. . ~ D~tIVE CENSE +f ~ s It#:'9821 CLA~3 ~ .. 1` n~ '. ~~ t. ` ~ V~'-~ 0.S". ~,, ,: :;, _ 3 t a ~ n ~; ~4,1fii'h~n' i~ ~ q MOVE .:- o-~s~z ~i oz-i~-su soot ,~ v,,. r • Application to Town/City Clerk NEW YORK STATE DEPARTMENT OF HEALTH for Copy of Marriage Record Vital Records Section Certification ~ Fee $10.00 Search andpy ^ Fee $10.00 Certified Co 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 Heath Department, includes the names of occurring on the original record of the marriage. the contracting parties, their residence at the 6me the license was issued as well as date and place of INrth 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) dle) (Last) d Name (Feat) (Mi of e of j ~ ~~1~~ ~ I/ - Groom ~ Ct rnb fC Cis ~v~ ~ rr,~d Bride • Groom's Age or Date of ( ~ j ~ i ~ v ~ ~ Bride's Age or Date of 3 / ~ 3 - ~' ~ Birth , Birth Residence (County) (State) Residence (County) (State) of E ~h t Sf Groom ~~ N ~ ~ Bride S Date of Marriage ff Bride Previously Covered Married, State Name ~ I 2 ~ f I Z ' b Sears Used at That Time Place Where Place Where . Was ~ Marri Was / '~/ c~ i v~ C ~.S N Issued Performed For what purpose is information required? What is your relationship ro person whose record is requested? if self, state'self." In what capacity are you acting? If attorney: Name and relationship of your client ro persons whose mamage recorcl is required. Signa of icant Date Address of A licant Please print name and address where record is ro be sent. U~ ti~<e~ Sig W ~ / Z(~ a / 5~Z Crt~c.l~ r~ DOH-301 (3/~i) (PLEASE SEE REVERSE SIDE) ~. NEW YORK STATE DEPARTMENT OF HEALTH Yrtaf Records section Application to Town/City Clerk for Copy of Marriage Record TYPE (JF F~EGORIa DE~tRE© (Ertt~r f~l~mber'>of copies) Search and Fee $t 0.00 Certified Transcript ^ per copy Search and Fee $t o.oo Certfied Copy er c o p Py A Certified Transcript is an abstract fiem the manage record issued under the A Certified Copy includes aA d the items d infamration oocuming an the original seal d the town/city clerk. It includes the names d the oor~acting parties, their record d the marriage. residence at the time fhe license was issued, date and place d manage as well as date and place d birth d the bride aid groom. A Certified Copy may be needed where prod d parentage and certain olhe r A Certified Transcript may be used as prod that a manage ooaxred. detailed infarrrratirarr may be required sudh as: passports, veteran's benefits , court prooaedings, a settlement d an estate. ~ridelGroomlSpcuse Name (as recorded on marriage lice nse): Dots of Birth: p Ne ~') l~ ~~t ~l ~.~.~~.~r..,~ '' ~2 N ~~. ~'la ~ 1 ~ 3 If Previously Married, State Name Used at that Time: Residence (at time of marriage): r~r rar°i' t~.r ~r apt. BridelGrooml~ouse Name (as recorded on marriage license): Date of Birth: ~eSA ~ ~~~ k~+~r•+ria..t..~:~ ry.r tads. ~ ar~nw.~. 1 ~~-~~~ ~ If Previously Martied, State Name Used at that Time: Residenxe (at time of martiage): c~ s~ Marriage lrrfatn __ Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Manage Certificate No.: Local Registration No.: Taman, ~~ ~~SS ~wN Dr~T~-sS A~ ~ Taan ar Tew~ ~- Purpose for which record is required: Date of Marriage or Period L ~s ~ ~~, grN ~ Covered ~v Search: d~ ~~ ~~g In what capacity are you acting?: What is yore relationship to person whose retard is requred? ~~~~~ S ~ ' ~ ~ (If self, state "SELF'.) ~~ ~~ Iw~w-~/ E..iad/my1 If attorney, give name and relationship of your client to person whose record is nsquired: Signature~pplicant Date: / ~ ~ ~ t~ ' ~ Applicant's hone Num r. ~ ~ ~.-~ I ~ J l (~ ~ ~- G ~ a- a~ 7 ~~ Name of Applicant: Please print name and address where record is to be sent: ~c~u,y e ~7~, ~~ ~ ~,~v Address of Applicant: ~~~r/vq-ers ~-IIS (~~1~-DOI~~i~ds r~1I1s N~~- (a~ry ~Y State ZIP nnu en..ei..~ d__ . _. n City Stab I1P ......w. ~w..~ . oyv ~ v~ ~ r ~ ~~ NEW YORK STATE DEPARTMENT OF HEALTH Yd~ Records Sedian Application to Town/City Clerk for Copy of Marriage Record TYPE OF R~+~ fl l~E~RE ~ ~Ert~lr f~i~rmbar a# Cv;pies) Search and Fee St o.oo Search and Fee $t o.oo Certrfied Transcript per copy ^ Certfied Copy per copy A Certified Transcript is an abskad from the age issued under the A Certified Capy indudes aN d the items d information accumng on the original seal d the townldty deck. It indudes the names d the oontrardirrg parties, their record d the marriage. residence at the dme the license was issued, date and place d manage as well as date and place d girth d the bride aid groom. A Certified Cagy may be needed where prod d parentage and certain other detailed irrfarmafian may be required such as: passports, veteran's benefits , A Certified Transcript maybe used as prod that a manage occurred. court praoeedmgs, err settlerrrent d an estate. '8ride~(3roorn/Spouse Name as recorded on marriage license): ~ ~ r 1 , Date of Birth: (or+a~er..or.~.ryoy ~ Ir ~ L1~ ~J Ifid~o airs None If Previ usly Married, State Name Used at that Time: Residence (at time of ma 'age). Bride{~rooml~ot>fse Name (~a~s ,re~cporded on marriage license): ~ , / -,, Date of Birth: ) ~ r~..r '~rr~. r..r arer u.» ~ U ~ ~ (~--~ If Previously Married, State Narr>e Used at that Time: Residence (at time of marriag ~~~ ~~ F..e rsaa. i,er ~r _._ . _..... Marriage< nfat mafort `; ........... Place Where Marriage License Was Issu,.ed": ~ ~~~ Place Where Mari ~~Wl~as P onned: Marriage Certificate No.: Local Registration No.: Tewi err Toes Pu for which record is required: ~ Date of Marriage or Period h ,, ~ ~ yY~ ~~ ~~. P~'~ ~ p/ ~ Vv ~~d-If~~S i ~ 11 ~1~OU~ Covered by Search: INrti~da-a ~°` `aeC r In what c~acity are you acting : tiuhat is your relationsh~ to person whose record is required? i yy~ (If self, stete'SELF'.) 8areb for ia~w+~lt 1r/dd/m7! If attorney, give name and relationship of your client to person whose record is required: Signature d Applicant Date: Applicant's hone Num r. ~ ~ ~ !S ~ ~~1 ~~ Name Applicant: Please print name and address where record is to be sent: 1 ~` , U~t" Ad ss d Applicarttt ~ G~ ~ ~ ~~ l ~ ~ - S 't City Stets ZIP City Stet ZIP ucm~oi ps/ni rape i of z _~ NEW YORK STATE DEPARTMENT OF HEALTH Applicartion to TownlCity Clerk for Copy of Marriage Record Vital Records Section ~ 1 TYPE pF .RECORD [~E~RED +(Entt~r dumber of Cc~pi~s) Search and Fee $~ 0.00 Fee $ t o.oo Search and Certified Transcript ^ Pef copy ^ Certified Copy per copy A Certified Transcript is an abstract from the marriage record issued under the A Certified Capy includes all d the items d information oocumng on the anginal seal d the tormlcity clerk. It includes the names d the oorrirading parties, Their record d the marriage. residence ffi the one the ficense was issued, date and pace a# marriage as well as date and dace d birth d the bode and Boom. A Certified Copy may be needed where prod d parentage and certain ocher detailed infamffiian may be requrced such as: passports, veteran's benefits , A Certified Transcript may be used as proof thffi a marriage occurred. court proceedings, or settlement d an estate. 'Bride[GroomlSpot~se __ Name (as recorded on marriage license): Date of Birth: for rrp at fiw of llnlriy~J 9 Gf/~ S arrr u r ' 4 ~ r /D ~ ~ Z- „ ~trr ~ way. . ..l. If Previously Married, State Name Used at that Time: Residence (at time of marriage): r~..e arradr. tar ~- i3ridelGroomtS'pouse Name (as recorded on marriage ficense): Date of Birth: ,y la-+wafill.aeeay F..r ~~PiLI ores. t,.r awn~l. ~ ~Z ~~ If Previously Married, State Name Used at that Time: Residence (at time of marriage): r~..r ~ 1 rwa~. ~.r s~ Marraga trtfonnat)on Place Where Marriage License W~as~Issu~ed: Place Where Marriage Was Perf~o°rmed: Marriage Certificate No.: Local Registration No.: - ~ G~~Z~G~~L;I ~ ~G~. ~ ,~ ~i.~ ~ ~ ~~~G ~%~J lei ~~-I which record is required: In what capacity are you acting?: ~ what is y reratwnsnip m person (If self, "SELF'.) CU~?~i If attorney, give name and relationship of your client to person whose record is required: Date of Marriage or Period Covered by Search: ~amda-w s..er tlo.r M..1/ed/~rrr1 u ~~ s..dl ~ ~71a11alYltl UI tJt1111~111 voaa. r~~n~w.ov ~ nv~F. nw~//~~/1 `Q ~,//}v/v^~/) Name of ica Please print name and addre s where record is to be sent: ~N/~' ~ o ,~ur~ ~S Address of Applicant I`~/1, ,~ 1l ~ Dol~ot irutt- wee t of z ~, ,~ ~:. i_ _ .._~.._,..sa~ ..~. NEW YORK STATE DEPARTMENT OF HEALTH Vrcat Reoads Section Application to TotttmlCity Clerk for Copy of Marriage Record _. TYPE OF'F~ECOR© QE~FE C~ Enter Number of Copies) Search and ~ Fee $t o.oo Certified Transcript per copy Search and ^ Fee $10.00 Certfeed Copy per copy A Certified Transcript is an abstract from the marriage record issued under the seal d the townldty dark. It indudes the naves d the cartradkrg parties, their residence ffi the time the license was issued, date and place d marriage as well as date and place d birth d the bride and groom. A Certified Trarsaipt may be used as proof thffi a marriage occurred. A Certified Capy indudes an d the items d information ooovmng an the original record d the marriage. A Certified Copy may be needed where prod d parentage and certain other detailed infarmerlian may be required sud- as: passports, veteran's benefits , court prooeerirrgs, ar settlement d an estate. i3ride<f3roarntSpouse Name (as recorded on manage license): R ~ ~~5 ~ ~ ~ Date of Birth: ~~~~~ -.~ . 1 a~ n ~ ~ ~. ~ mow.. 3 a ~ ~7 a- If Previously Married, State Name Used at that Time: Residence (at time of marriage): )~u~-che55 ~v~ First ~~ Iasf SrM &idel~Groom/Spoutse Name (as recorded on marriage license): Date of Birth: r-.,r trwt~. t,.r eHn N.r. ~ 2-' 30 l If Previously Monied, State Name Used at that Time: Residence (at time of marriage): r•..r nraa. t,.t arsr _... ........ __.._ __ Marria~e;lnfot r~a~iotl Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~~~~ ir~ger5 ~~-(c~e Tewr ar ~o h~'~(Q ~crlc~i~ Town a ~-e».,- Purpose for which record is required: Date of Marriage or Period ro ~ O ~ ` ' ~~ C(~l~n ~/i C~~ ~Jl Y ~ Covered by Sean:h: ~.r,a w $"`` `°°c ' In what capacity are you acting?: What is your relationship to person MAase is required? ~ (If self, state "SELF'.) pQ C~ ( M.r/ddi~ Seneb Iar If attorney, give name and relationship of your client to person whose record is required: Signature of Applicant Date: s Ptt~ bar. App6 C~.~-rum to la ~'S~"{ 8 Name of iant: ~~ ~(~ SSC~I' ~ Ple print name and address where record is to sertt: ~Ct 2 4 2~,'2 Addressd pliant: OF ~/~P ~'1I (..Q PIN~ER r0 CAy State ZIP Ciry State ZIP DOH,301 X11) Papa 1 of 2 ,r~~. _._, -__ ~ ~~1 ;~ ~. NEW YORK STATE DEPARTMENT OF HEALTH Application to TownlCity Clerk for Copy of Marriage Record Vital Records section TYPE OF RECORD DESfRE ~ {En}ter Number of Copies) Fee $10.00 Search and Search and Fee $10.00 ~ Certfied Transcript per copy ^ Certified Copy per copy A Certified Trarsaipt is an abstract Fran the marriage record issued under the A Certified Copy includes all of the items of information ocarmng an the original seal of the townloty clerk. It includes the names of the oorrtracting parties, their record of the marriage. residence at the time the license was issued, date and place d manage as well as date and place of birth of the bride and groom. A Certified Capy may be needed where proof of parentage and certain other detailed irdamation may be required such as: passports, veteran's trenefds , A Certified Transaipt may be used as proof that a manage ooalrred. court praosedmgs, a settlement of an estate. $1!Id@{GroOrty$p011Se Name (as recorded on marriage license): Date of Birth: >~ ~ >~ ~~. If Previously Married, State Name Used at that Time: Residence (at time of marriage): ti ~ .~~~-~ ~~5s ~ Y Fisr IRd~a !#N ~h StaN $rltje~~rQt>In/~O~iSB Name (as recorded on marriage lic nse): Date of Birth: e \ r ~ymoll~ l` 1Jol'~IhG~Q/~ l ) ~-/ z ~~~ ~ Now Fisf"' Yrd~r larf ~- 6 -f If Previously Monied, State Name Used at that Time: Residence (at time of martiage): ,~~ d ~ ~ ~~~~~~~s ~Y a~ __ Marriage r~forrrfat~n Place Where Marriage License Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: `~~ .~ "1°I° ` ~~ers ~icl ~ 5 .~ ~.~}"c l1 e ~5 Tew~ err Tear M Purpose for which record is required: Date of Marriage or Period co ~S ~zv~~ ~ ~~ ( (Z k Covered by Search: .. : t~1ad aA a/ ~: In what capacity are you acting?: tlVtret is yore relationship to person whose record is requved? ~~ t~l S ~ ~ ~ (If self, state "SELF'.) S n s..en ra: ~ ~~~ e~ Q- aw 9 ~ rrrr- l If attorney, give name and relationship of your client to person whose record is required: Signature of plican Date: Applicant's hone Number. Name of icant: Please pri d address whpra rp„mrd is t t; a.~ r.,~o ~1 c~ ~o (~r vt~ 2.,'' D D Address of Applicarrt: ~ 3 C,~~,~~~s ~{~~, (~~~A~nq~,/.5 ~~((`s IJ `l~ ~ 2-5917 TOWN CLERK City Sfate ZIP Ciry Sfa<e ZIP DOH301 (8It1) Pape t or2 NEW YORK STATE DEPARTMENT OF HEALTH vrt~ Records Sedian Application to TownlCity Clerk for Copy of Marriage Record :TYPE 4F ICE QRf3 QE~fREf ) ~Entar ~I~mber of Copies) Search and Fee $t o.00 Certified Transcript Pef SPY Search and ^ Fee $t o.oo Certified Copy per copy A Certified Transaipt is an abstract from the marriage record issued under the seal d the townldly deck. It mdudes the names d the oorttrading parties, their A Certified Copy itrdudes all d the items d information ocwning on the arignal record d the marriage. residence ffi the time the license was issued, date and place d marriage as well as dffie and place d forth d the bride and groom. A Certified Capy may be needed where prod d parentage and certain other detailed irrfamation may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof tl>at a manage occurred. court proceedings, ar settlement d an estate. Bri roort~ISpouse Name (as recorded on marriage license): ~~,Q / ~~- ~ Itidd~ tat L.L I t° y aii~er~ N.u Date of Birth: ~ / ,~rr.~.~ / ~ ` 7 c~ ~0 cA7 If Previously Married, State Name Used at that Time: Resi nce (at time of marriage): ~u ~~t 2ss ~/U~ wdw. ~ ~ ' use ~id~ Na (as recorded on marriage license): /~ ~~~ ~ /~~~~ `~- ~ Date of Birth: (arayraf 6M or~reipy area tr... ~ was. ~ If Previously Monied, State Name Used at that Time: Resi rs;e (at time of marriage): A > J! Gt°l~-2cS~ ~v / ~ wade t,~r ~+ Marriage inforrnsti Pla~celWhere Marriage License Was Issued: ~' Uhl r e •' ~ ~ Tam ~ ~ Place here Marriage Was Performed: / U ~~L~JQd~-~ /~ Tam a / Marriage Certificate No.: Aa..a Local Registration No.: w Purpose for which record is required: Date of Manage or Period ~~~e~C ~~ ~~ /~ Covered by S/earth: ~j 2 In what capacity are you acting?: /~ ~L j~ L C Whet is y~ relationship to person whose record is required? (If self, state "SELF".) ~Q / ~ (~L/' f„„~~~~ s~d-foc p~w+~ f~laal~l If attorney, give name and relationship of your client to person whose record is rec~ired: Si nature f A icant Date: ~ Applicant's home Number. a of Applicant: ' ~~ ease 'nt name and address where record is to be sent: Address of Applicant: auG 2 s 2o~z TOWN OF WAPPIN ER ~y Slate ZIP Cdy Stet. Z1P DOH301 (81t1) Papa t of 2 u~9~ NEW YORK STATE DEPARTMENT OF HEALTH Vitd Records Sedicn Application to TownlCity Clerk for Copy of Marriage Record TYPE O~ #~ECOR#~ QER~ ~ (Enter'~~lumber u# iss~ Search and Fee t610.0o ^ i ~ S Search and Fee $10.00 ~ per copy Certified Co pt Certfied Transcr P PY py A Certified Trarstxipt is an absUad from the manage record issued under the A Certified Copy indudes all d the items d irdormation ocalmng on the original seal d the townlaty deck. It indudes the names d the coMradmg patios, their record d the marriage. residence at the dme the fioense was issued, date and place d manage as wetl as date and place d birth d the bride and groom. A Cafified Capy may be•needed where.prod.. d parentage aid certein~ether detailed irrfamiadian may be required such as: passports, veteran's benefits , A Certified Transaipt may be used as proof that a manage occurred. court proceedings, a settlement d an estate. 13ride1Groom/5pouse Name (as recorded on marriage license): Date of Birth: faew+t t:^.oterriysJ If Previously Married, State Name Used at that Time: Residence (at Gme of marriage): Fist tllydd~ IiM Sir Bridel~GroorNSpourse Name (as recorded on marriage license): Date of Birth: fe. a<6e.err-ips) If Previously Married, State Name Used at that Time: Residence (at time of marriage): Ma~risga nforrttaf~on Place Where Marriage License Was Issued: Place Where M age Was Performed: ' Marriage Certificate No.: Local Registration No.: U~~P~~~rn~,'1Q1^r`'tl' ~~.~~ ~ (~~u~c~- 'tt +~1'1c~n~~ Amt 7ew~or "--"' 'tea Purpose for which record is required: Date of Marriage or Period ~~ ~ ~ ~~-,. A Q~,~S~T ~ ~-1~ ~.~~~' V~ 1 M Covered by Search: ] ~~ ~ ~~aoi~ In what capacity are you acting7: What is you relatiorrsh~ to person whose record is requved9 ~~~~~ ~~~~ (If self, state "SELF'.) _ SSt~- s..~b: ~s..etigpwfodl (isuldd/g7Y) If attorney, give name and relationship of your dient to person whose record is required: Signor ref pliant Date: Applicant's hone Number. - ~~~ - g(~I I2- ~~s~ ~G~ ~ los3 time of Applicant: Please print name and address where record is to be sent: ~,1 ~ N D I ~ . C ~~M ~M~ Address of A rcartt ~~n ~~Is ~~-I Iasgo Stoma ZIP City State ZIP DOH-901 (8111) Pepe 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Application to TotivnlCity Clerk for Copy of Marriage Record Vital Reocrds Section TYPE Di= F~ECOR©1~~~#FE D ~Ent~r dumber of Copies) Search and ^ Fee $10.00 t i d T i C ef ~ Search and ^ Fee $10.00 per copy rtified C C ranscr ert p fie P pY e opy A Certified Transcript is an abstract from the marriage record issued under the A Certified Copy indudes all d the items d information ocatmng on the original seal d the townlaty deck. It mdudes the names d the oontrading parties, their record d the maniage. residence at the time the fioense was issued, date and place d marriage as well as date and ~aoe d birth d the bride and groom. A Certified Capy may be needed where proof d parentage and certain other detailed information may be reoxbred such as: passports, veteran's benefds , A Certified Transcript may be used as proof thffi a marriage occurred. court prooeedmgs, or settlornent d an estate. __ BridelGcooml5pouse Name as recorded on marriage license): ~V~ ~ '~ ~ Date of Birth: /orey.ar~..a..riy~j - v1ti ~-JC~ ~ l~~~~~ ~ ~. t,.r e:mtrf.» If Previously Monied, State Name Used at that Time: Reside at time of age): ~-~ ~~. ~y &idelGrot~trtlSpo-tse Name (as recorded on marriage license): J Date of Birth: (aeyeattwuefare~iry~- ~~ ,[~ ,~. /~/~ 1~~~~ / ~ ~' / l~L- ~ j ' Z3 z~ ~ ty.» ( tat raider ~ ~ If Previously Monied, State Name Used at that Time: Residence (at time mama 1~N~-S~ w ~ tsrae. r,.r ~ ~ ~ aeM. _... Marriage trtforntatbn Place Where Marriage license Was Issued: Place Where Marriage Was Performed: Marriage Certificate No.: Local Registration No.: ~ v~ ~' ~ /J(~ ~it T , c J~ Tea i~ . for ich record is required: Date of Marriage or Period { /~ Covered by Search: In what capacity are you acting?: What is yore re~tionship to person wfrose retard is requved? ~,,,,~~~~ (If salt, state'SELF'.) 8nrob br Ia...d+igPwadl Ea./du/my- If attorney, give name and relationship of your client to person whose rer.~rd is r+a~ired: Signature p cant Date: AppG s Phone Number. N e of Applicant: Please print name and address where record is to be sent: -___ __- Add of Ap - rtt: ~'~ ~~ U~s~--- v°~l~ z~3 ~ City State ZIP Cdy State ZIP DOH~01 (tuft) Pape 1 of 2